Aging and HIV-Related Caregiving in Sub-Saharan Africa: A Social Ecological Approach

Aging and HIV-Related Caregiving in Sub-Saharan Africa: A Social Ecological Approach Abstract Background and Objectives We reviewed the literature on older adults (OAs) who are caring for persons living with HIV/AIDS in sub-Saharan Africa (SSA), with the goal of adapting models of caregiver stress and coping to include culturally relevant and contextually appropriate factors specific to SSA, drawing on both life course and cultural capital theories. Research Design and Methods A systematic literature search found 81 articles published between 1975 and 2016 which were reviewed using a narrative approach. Primary sources of articles included electronic databases and relevant WHO websites. Results The main challenge of caregiving in SSA reflects significant financial constraints, specifically the lack of necessities such as food security, clean water, and access to health care. Caregiving is further complicated in SSA by serial bouts of caring for multiple individuals, including adult children and grandchildren, in the context of high levels of stigma associated with HIV. Factors promoting caregiver resilience included spirituality, bidirectional (reciprocal) caregiving, and collective coping strategies. Discussion and Implications The creation of a theoretical model of caregiving which focuses more broadly on the sociocultural context of caregiving could lead to new ways of developing interventions in low-resources communities. Caregiving, International issues, Stress and coping The confluence of population aging and the HIV/AIDS epidemic in sub-Saharan Africa (SSA) has resulted in a wide range of psychosocial and health impacts that are not fully understood (AVERT, 2015). SSA accounts for 70% of all cases of people living with HIV/AIDS (PLWHA), with prevalence ranging widely across the different countries in the region (UNAIDS, 2015). HIV/AIDS has eroded the working capacity of communities, and affected needed financial and material support to survive (Kang'ethe, 2012; Knodel, Watkins, & VanLandingham, 2002). Thus, many older adults (OAs; 50+) have been forced into primary caregiving roles as younger adults, who would normally provide support to aging parents and their children, died from HIV/AIDS (Mathambo & Gibbs, 2009). Given the contextual nature of older adult (OA) care giving in SSA to PLWHA, it is important to understand the role of context (aging, HIV/AIDS, war, poverty) in the development of effective interventions. In SSA as elsewhere, care is shaped by the culture which informs the dimensions of “good” care, culture-specific approaches to symptoms and illness, and bereavement (Gysels, Pell, Straus, & Pool, 2011). It is critical to address resource deficits for PLWHA and surviving orphans, including lack of basic infrastructure, food insecurity, and poor record keeping (Njororai & Njororai, 2013; Oppong, 2006). Unemployment and industrialization may also play a critical role in the recruitment of OA caregivers, as these forces often lead to urban migration and high prevalence of HIV/AIDS which, in turn, resulted in the creation of orphans and vulnerable children (OVC; Dolbin-MacNab & Yancura, 2017). Patriarchy and the marginalization of women exacerbates care deficits (Schatz & Seeley, 2015). Women, and increasingly OA women, provide most of the informal care in SSA. The emergence of male caregivers who provide both instrumental (financial) and nursing care is reflective of a larger demographic shift related to the feminization of labor in urban centers and the lack of employment for men (Block, 2016; Block, 2014). The main goal of this review article is to extend sociocultural models of stress and coping to a true multilevel model which incorporates the impact of the larger historical context on social institutions, which in turn affect individual level stress and coping practices. We will do this through focusing on the impact of cultural resources on caregiver wellbeing in OAs providing care to persons with HIV/AIDS. Sociocultural Models of Stress and Coping Sociocultural values are important for the caregiving process (Pearlin, Mullan, Semple, & Skaff, 1990). Using Hispanic American caregivers as exemplars, Aranda and Knight (1997) defined culture in terms of a bipolar dimension of individualism and familism. They hypothesized that individuals adhering to individualism would report higher levels of caregiving burden because the provision of care would interfere with the caregiver’s autonomy, whereas those adhering to familism would report lower levels. Surprisingly, this was not supported by their data. Knight and Sayegh (2010) recommended that additional research on ethnic differences in caregiving needed to explore a range of finer-grained dimensions of cultural values that are associated with both positive and negative effects on caregiver health outcomes. Aldwin (2007) suggested that cultural values influence coping resources, including social support and coping strategies, as well as the cognitive appraisal of burden, which might prove to be a fruitful avenue for expanding the model. Following Knight and Sayegh’s (2010) recommendations, we expanded their stress and coping model (see Figure 1). (Knight and Sayegh’s original model is highlighted by a gray background.) The model consists of three levels: the sociohistorical, the intermediate, and the individual contexts. We drew on life course theory (Elder & George, 2016), which posits that individuals’ developmental paths are embedded in and transformed by local and global contexts and events that occur in the historical period and geographical location in which they live. In our model, the sociohistorical level is represented by the current confluence of population aging and the HIV epidemic. In SSA, the role of OA has been transformed in part because the HIV/AIDS epidemic has resulted in over a million deaths among working age adults (15–49), creating a “missing generation” (AVERT, 2015). Figure 1. View largeDownload slide Sociocultural multileveled model of stress and coping. Sayegh and Knight’s model is highlighted in gray. Figure 1. View largeDownload slide Sociocultural multileveled model of stress and coping. Sayegh and Knight’s model is highlighted in gray. The second level of the expanded model in Figure 1 reflects Bourdieu’s theory of cultural capital or resources as the intermediary link between the larger sociohistorical context and immediate context of care (Bourdieu, 1986). Conceptually, culture can be understood to be a resource or capital that can be spent, bartered, saved, discarded, created, or extinguished. Five types of cultural resources have been identified (Bourdieu, 1986; Heckman, 2007). Material capital includes the built environment, including hospitals, housing, transportation, food production, and sanitation systems (Lynch, Smith, Kaplan, & House, 2000; Ralston, 2017), and is a predictor of health and wellbeing among OAs (Ralston, 2017). Financial capital refers to access to tangible assets that can be used to purchase goods and services (Galama, 2015). Cultural capital refers to one’s knowledge base, skill sets, assets, and social status (Bourdieu, 1986). Social capital refers to resources linked to social networks. The amount of social capital depends on the size of network connections and the resources possessed by network members. Human capital refers to an individual’s genetic assets concerning appearance, intelligence, and talents, as well as their health status (Heckman, 2007). Note that culture also includes barriers to resources in these categories, such as some inequalities, health disparities, and social stigma. The third level is the individual level and involves matching the situational demands of caregiving with the cultural resources needed to utilize or create coping strategies in response to these demands (see Aldwin, 2007). The double-headed arrows in the model suggest dynamic, transactional relationships among established cultural resources, caregiving situational demands, caregiver needs, and the resources available to caregivers. When the system is in a state of disequilibrium, caregivers may create new cultural resources to meet these demands. Caregiver resiliency is the ability of caregivers to adapt by using thee cultural resources, and is illustrated by the movement from the intermediate level to the individual level (Aldwin & Igarashi, 2016). Our expanded model differs from Knight and Sayegh’s model in two distinct ways. First, we have expanded their definition of cultural values to refer to resources that can either be pre-existing or newly created to meet ongoing caregiving demands. Secondly, their model focuses on caregiving for patients with dementia, but we believe that this expanded conceptual model may be applicable to a wide range of illnesses and caregiving situations, including HIV-related caregiving. We will apply our conceptual model to the systematic review of the literature on OA caregivers to persons impacted by and/or living with HIV/AIDS in SSA. Methods Approach and Search Strategy We searched both peer-reviewed and gray literature sources for articles published in English between January 1, 1975, and December 31, 2016, on OAs caring for HIV-positive family members in SSA in the following databases: MEDLINE, PsycINFO, Social Sciences Citation Index, CINAHL, Cochrane Library, Africa-Wide: NiPAD, and relevant WHO websites. Articles were included if they met the following inclusion criteria: conducted in SSA; sampled OA caregivers, aged 50 and older; used community samples; and focused on HIV-related impacts. There were no restrictions on sample size or study design. Articles were excluded if they were not available in English. Identified articles from all sources were imported and duplicates removed. Titles and abstracts were read, and if deemed appropriate, the full article was obtained and coded. Organizing the Information Caregivers were defined as adult women or men aged 50+ who are providing care to PLWHA and/or children younger than 18 who may or may not be HIV-positive, but need care because of HIV. Most the articles included in this review had an aspect of caregiver stress/burden, orphan caregiving, or the impacts of caregiving on caregiver health, wellbeing, and finances in the title or abstract. We used a narrative approach similar to Yee and Schultz’s (2000) review of the empirical care giving literature. The diversity in measures used and the heavy reliance on qualitative research made a meta-analysis inadvisable. Several steps were used in organizing this review. Our first step involved summarizing the studies by constructing a table containing the country, sampling strategies, main topical domain, and the salient findings for each study). We considered organizing the articles by country, decade or other time variable (pre-and-post apartheid in South Africa), but there did not appear to be any substantive differences in the reported findings since the late 1990s when this topic first appears, and instead opted to organize it by country and publication date (see Table 1) for heuristic purposes. Table 1. Summary of Sub-Saharan Africa Studies on Older Adults Caregiving for HIV/IADS Family and Friends Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Note: BMI = Body mass index; CG = caregiver; CR = care-recipient; OA = older adult(s); OVC = orphan and vulnerable children; PLWHA = person(s) living with HIV/AIDS. aHealth behavior. bAcceptance of self and life events. cNongovernmental organization. View Large Table 1. Summary of Sub-Saharan Africa Studies on Older Adults Caregiving for HIV/IADS Family and Friends Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Note: BMI = Body mass index; CG = caregiver; CR = care-recipient; OA = older adult(s); OVC = orphan and vulnerable children; PLWHA = person(s) living with HIV/AIDS. aHealth behavior. bAcceptance of self and life events. cNongovernmental organization. View Large We grouped these items into the categories defined by our theoretical model to illustrate the importance of cultural resources on informal caregiving. Finally, where appropriate, we noted examples of health outcomes across the three broad domains of health resource strains, health behaviors, and health outcomes. Results A total of 122 articles were identified from the databases, out of which a total of 81 met all the selection criteria and were used in the study. Articles were excluded because the topic did not include caregivers (n = 17), the caregiver was too young (n = 9), the study was not based in SSA (n = 11), or did not meet other criteria (n = 3). Out of the 81 reviewed articles, most were situated in South Africa (n = 31), followed by Kenya (n = 16), and Uganda (n = 9), Zimbabwe (n = 7), with the remaining studies in Botswana (n = 5), Ghana (n = 2), Lesotho (n = 1), Malawi (n = 2), Nigeria (n = 1), Tanzania (n = 3), and Togo (n = 2). Two cross-sectional studies on OA caregivers examined five or more countries at once. The articles described a variety of methods to collect data including, qualitative data collection (44%), cross-sectional and longitudinal quantitative studies (51%), and mixed-methods research studies (5%). Situational Demands The deaths of prime-age adults have altered household composition and access to resources (Adamchak, Wilson, Nyanguru, & Hampson, 1991; Agyarko, Madzingira, Mupedziswa, Mujuru, & Kanyowa, 2002; Ainsworth & Dayton, 2003; Cohen & Menken, 2006). The articles detailed the poor infrastructure, such as the lack hospitals, medications, access to land, irrigation and modern farming techniques, food distribution, and transportation, as well as widespread unemployment, food insecurity, and climate change. This impacts OA caregivers’ ability to provide safe and effective care to PLWHA and to OVC (Ainsworth & Dayton, 2003; Juma, Okeyo, & Kidenda, 2004; Muga & Onyango-Ouma, 2009). For example, in Tanzania, early publications reported that social safety nets were compromised (Kaijage, 1997), hospitals were overwhelmed (Uys & Cameron, 2003), and food insecurity was commonplace (United Republic of Tanzania, 2006). Recent reports from Tanzania suggest that little has changed. HIV-related stigma and discrimination, stress, and care burden continue to challenge resources for caregiving (de Klerk, 2011; Pallangyo & Mayers, 2009). AIDS-related deaths have resulted in the creation of 12-million orphans who have largely been absorbed into extended family networks comprised of OAs (Hlabyago & Ogunbanjo, 2009). In most countries in SSA, the extended family, primarily grandparents, care for a large number of OVC (HelpAge International, 2008; Monasch & Boerma, 2004). In national household surveys conducted in 40 countries, only 13 of the countries included information on OA caregivers (Monasch & Boerma, 2004). In those 13 countries, between 24% and 64% of OAs were fostering OVC affected by HIV/AIDS. In Malawi, OAs cared for nearly half (46%) of orphans who have lost both parents. Despite the relatively low prevalence of HIV/AIDS in Kenya, the percentage of OAs providing care increased from 11% in 2006 to 14% by 2014 (Chepngeno-Langat, 2014). In Namibia, the proportion of orphans being cared for by grandparents rose from 44% in 1992 to 61% in 2000 (UNICEF, 2003). In Zimbabwe, South Africa, and Namibia, 60% of AIDS orphans lived with OA caregivers (Zimmer & Dayton, 2005). Caregiving for OVC has some positive aspects. In Kenya, OVC in the household was associated with better health outcomes for men (Ice, Juma, & Yogo, 2008). In Botswana, a country with the second highest prevalence of HIV/AIDS in the world (17.6%), both children and OAs provide bidirectional care (Lindsey, Hirschfeld, Tiou, & Neube, 2003). Similar patterns of bidirectional care were reported in Kenya and South Africa (Petros, 2011, 2012; Skovdal, 2010). Often, OAs are receiving care for non-HIV or HIV-related health issues or personal care (Nyirenda, Evandrou, Mutevedzi, Hosegood, & Falkingham, 2015). In SSA, OVC often do necessary chores, such as hauling water, tending animals, and so on, which helps both to fill in the labor gap caused by parental death and helps the grandparent’s household economy (Sidloyi & Bomela, 2016; Skovdal, 2010). This care work by OVC is not purely instrumental. In Uganda, the care work for OA caregivers was described as compassionate, highly desired, and loving (Rutakumwa et al. 2015; Seruwagi 2014). Food insecurity, reported in most of the reviewed articles, is perhaps one of the most unanticipated effects of the HIV/AIDS epidemic. This stems in part from the loss of working age adults, access to land, inheritance laws, and an overall of loss of productivity due to poverty (Agyarko et al., 2002; Mwanyangala, Mayombana, & Urassa, 2010; Pallangyo & Mayers, 2009), time spent caregiving, lack of knowledge of modern farming techniques, increased household size, aging, and chronic health problems (Nyirenda et al., 2015; Oburu, 2005; Wangui, 2009). OAs who cared for very young children seem to be particularly burdened (Shaibu, 2013). In summary, the HIV/AIDS literature has largely focused on the impacts of caring for OVC rather than OAs caring for both adult children and grandchildren. Research is needed on the influence of HIV-related caregiving responsibilities versus other types of informal care and how care recipients are affected when an established caregiver experiences a decline in health or functional status. Caregiver Needs Caregiver needs reflect the range of resources required for support. Included is the availability of resources that directly impact caregiver performance in assistance with activities of daily living (ADL), and instrumental activities of daily living (IADL), such as the access to financial capital, social support (social capital), and caregiving know how (cultural capital). Financial Capital The main source of income for caregivers varied by country. In South Africa, the majority of OAs depend on the old-age pensions and cottage industries, e.g., selling fruit, milling grain, or providing other nondurable goods and services (Bachman-DeSilva et al., 2013). The impact of public transfers are considerable; a Cape Town study found no differences in expenditure patterns between households with orphans, AIDS-related deaths, and other OA households (Ardington et al., 2010). Household subsidies did initially promote stabilization of households in SSA (Raniga & Simpson, 2010). However, the subsidies were not enough and subsequent studies reported that OAs were financially worse off after providing care to a family member with HIV (Bachman-DeSilva et al., 2013; Casale, 2015; Casale & Wild, 2013; Cohen et al., 2015; Kidman & Thurman, 2014). Many SSA countries do not have broad pension coverage, and poverty consistently impinges on cultural resources throughout the region. Reasons for economic insecurity center around six recurring themes. First, caregiving duties prevented engaging in income-generating activities (Chazan, 2008; Juma et al., 2004; Shaibu, 2013), and second, there were fewer family members available to farm and tend cattle (Lindsey et al., 2003; Wangui, 2009). Third, repeated bouts of caregiving depleted household resources (Chepngeno-Langat, 2014), often resulting in the fourth problem, poor health. Fifth, what few government grants exist are often inconsistent, insufficient, and nonaccessible (Bachanas et al., 2001; Hlabyago & Ogunbanjo, 2009; Petros, 2012; Tamasane & Head, 2012). Finally, HIV-related caregiving resulted in a lack of support from surviving sons and daughters, as well as inheritance inequalities among male and female family relatives. Thus, there are multiple pathways to poverty among older caregivers. Social Capital Despite the large literature on caregiving and PLWHA in high-income countries (HICs; Prachkul & Grant, 2003), most studies only examined instrumental social support and stigma. Several SSA studies reported that OA caregivers continue to experience a shortage of informal supports from family, friends, or neighbors (Alpasian & Mabutho, 2005; Boon, Ruiter, et al., 2010; Nyambedha, 2007; Nyambedha, Wandibba, & Aagaard-Hansen, 2003). Most OAs in South Africa (86%) reported that they were solely responsible for providing basic need for dependents (Boon, Ruiter, et al., 2010). In Malawi, only 31% of OAs were dependent on adult children for help (Sefasi, 2010). In Kenya, social support was linked to increased pain and higher BMI scores (Ice, Heh, Yogo, & Juma, 2011; Ice et al., 2008; Wangui, 2009). Instrumental support from nonfamily sources was equally strained. Several studies reported that OA caregivers were not treated with respect by governmental official and by hospital staff, including doctors (Hlabyago & Ogunbanjo, 2009; Mwinituo & Mill, 2006; Tamasane & Head, 2012). OA caregivers experienced many forms of stigma. In Botswana, OAs reported a sense of loneliness and isolation and that stigma was experienced by both caregivers for PLWHA and other chronic diseases (Lindsey et al., 2003). Caregivers in South Africa reported verbal, voyeuristic, and physical stigma (Hosegood & Timaeus, 2006; Lindsey et al., 2003; Ogunmefun, Gilbert, & Schatz, 2011). In Ghana, OA caregivers go to great lengths to hide the HIV status of care recipients as well as their caregiving activities, resulting in isolation of both the PLWHA and the caregiver (Mwinituo & Mill, 2006). Coping Strategies Studies of coping mainly addressed financial strategies and religious/spiritual strategies. OA caregivers coped with financial strain by using their knowledge and social networks to access old-age and foster-care grants, as well as their saving accounts (Ardington et al., 2010). In Kenya, OA caregivers engaged in small-scale farming and the selling of assets to meet the ongoing care needs of PLWHA and funeral costs (Wangui, 2009). There is some evidence that OAs in South Africa use a revolving pool of microcredit as a source of income (Lackey, Clacherty, Martin, & Hillier, 2011; Ogunmefun & Schatz, 2009; Schatz & Ogunmefun, 2007). Additional coping strategies included: applying for food grants, carefully managing income, investing in funeral insurance and credit programs, and creating associations to form social support networks (Casale, 2011; Chazan, 2008, 2014; Juma et al., 2004). Several studies reported the use of spirituality as a coping mechanism (Drah, 2014; Shaibu, 2013). In South Africa, caregivers reported talking to their pastor, congregants, and praying to God (Chazan, 2008). Alternately, silence and concealment of AIDS illness was a coping mechanism identified in South Africa to protect and honor individuals affected by HIV/AIDS (de Klerk, 2011). Health Impacts Health Resource Strains There are several unusual characteristics of HIV-related caregiving in SSA. The first is serial caregiving—many OAs care for one adult child, and then another—either concurrently or sequentially, as well as their offspring. In Kenya, 10% of noncaregiving OAs in a household transitioned into caregiving and 50% of these caregivers were providing care transitioned to noncaregiving status (Chepngeno-Langat & Evandrou, 2013). A second feature is the number of care-recipients, which are generally not analyzed with regard to caregiver health outcomes or asset dissolution. Caregiving is associated with high opportunity costs where OAs must forgo gainful opportunities to provide care (Nyambedha, Wandibba, & Aagaard-Hansen, 2001). Health Behaviors Health behaviors were only examined by two studies. In the first, OA caregivers reported foregoing meals, restricting their food intake, or working extra jobs to purchase the care-recipient’s preferred food (Kruger, Lekalakalamokgela, & Wentzel-Viljoen, 2011). The second study found that alcohol abuse was problematic for OA caregivers in South Africa (Sidloyi & Bomela, 2016). Health Outcomes Grandparents are grieving both for their adult children and report stress in caregiving for grandchildren. In Botswana, OAs had “disenfranchised” grief: they had to hide their own pain of losing adult children because they had to serve as a source of strength to the surviving grandchildren (Thupayagale-Tshweneagae, 2008). Grandmother caregivers in Botswana, Togo, and Uganda reported that they felt depressed and isolated, with a loss of control when grandchildren were unruly and disrespectful (Kamya & Poindexter, 2009; Moore, 2007; Thupayagale-Tshweneagae, 2008). Over half (57%) of Kenyan caregivers reported a poor quality of life and 74% reported that caregiving had a large impact on their lives (Lindsey et al., 2003). Kenyan caregivers of HIV-positive kin had poorer self-reported health compared to other types of caregivers. Men reported worse health than women and new caregivers were more likely to report having a major health problem compared with those who had never provided care (Chepngeno-Langat, 2014). Thus, the majority of the studies find impaired mental and physical health among caregivers, perhaps due to their greater poverty and age. Discussion The literature on OA caregiving in SSA is fragmented across several disciplines. Despite the more robust literature on HIV-related caregiving in HICs, much less is known about OA caregivers providing HIV-related care to adult children and grandchildren in SSA. This is important because, in many ways, the situation in SSA presages a dilemma that HICs will be facing in the next few decades—namely, many OAs will be requiring care and there will be too few caregivers (AARP, 2013a, 2013b). We found that OA caregivers in SSA face a range of challenges that can be framed by the sociohistorical context of population aging and AIDS. Further, our adapted cultural resources model emphasizes the collective nature of both the stressors and adaptive strategies. Most of the articles reviewed focused on material and economic resources, with comparatively fewer about psychosocial resources such as nonfinancial social support and coping in the SSA context. Although access to “public goods” is critical to caregiver wellbeing, it does little to address contextual factors such as, inheritance rights, intergenerational conflict, HIV-stigma, and rising dependency ratios (Lackey et al., 2011; Ralston, 2017). Another topic not addressed in the reviewed literature was related to the development of post-colonial migrant labor patterns (Camlin et al., 2010). However, the relationship between migration and AIDS is complex, and most individuals move to urban centers for economic benefits. Whether this applies to OA caregivers is unknown. Our multileveled model allows for the capturing of the social-cultural context of caregiving in SSA (population aging and HIV/AIDS pandemic). Studies reviewed consistently reported resource constraints that framed the situational demands of care including: lack of material capital (safe housing, roads, and transportation); lack of inheritance rights; and lack of food security (Ice et al., 2011; Lackey et al., 2011). These stressors were further augmented by the necessity of needing to care for multiple family members, either serially or at the same time (Chepngeno-Langat, 2014; Zimmer et al., 2005). A significant finding was that the bidirectionality of caregiving was often emphasized. Grandchildren were not only the recipients of care, but they also provided much needed household and farm labor which enhanced their grandparents’ ability to provide care (Kasedde et al., 2014; Petros, 2012; Skovdal, 2010). The care by OVC was not purely instrumental (e.g., running chores). OAs draw strength from their OVC and attach a great deal of importance to the quality of their relationships (Seruwagi, 2014). Third, at the individual level, the use of cultural resources was linked to a range of coping strategies, such as religious/spiritual coping, which is a very important resource. However, the collective nature of some of the coping strategies allowed for leveraging in resource-poor environments. Villagers reported communal strategies for financial and nutritional shortfalls, as well as for accessing often-distant medical care and meet cultural demand of funeral costs (Njororai & Njororai, 2013). The relationship between caregiving and caregiver physical wellbeing was more complex. Several studies reported poor health outcomes, but a few studies reporting positive health outcomes. Some of this may be due reverse causality—younger and healthier individuals may take up caregiving duties. However, there is some evidence that having a purpose in life may prove beneficial for older caregiver’s health (Casale, 2015). The SSA grandparents are often literally the only factor preventing complete destitution of their households, which provides a powerful incentive for maintaining functional health. Despite the resource-poor environment in SSA, many OA caregivers nonetheless exhibited resilience. They drew on their religious/spirituality, their sense of purpose, and their embeddedness in the communities. Despite social stigma, they often utilized collective strategies. Finally, this review emphasized the importance of OAs—in holding together their families and cultures in the face of an overwhelming pandemic and economic pressures. Conclusion and Future Directions The current body of evidence uncovered in this literature review partially supports our adapted conceptual model. This model allows for an integrated understanding of the stress and coping processes stemming from the wider cultural context. By identifying cultural resources and the collective nature of coping and adaptation in a resource-poor environment, our model provides a framework for caregiver intervention that is not solely focused on the individual, but recognizes the importance of targeting community-level efforts in interventions. Bidirectional caregiving is emerging as an important construct (Nagpal, Heid, Zarit, & Whitlatch, 2015). We need more research understanding the dynamic transactions between family members, friends, and the larger community to understand the resources that can be both drawn on and created during stressful situations. Next steps for research in this field should include the identification of processes that fortify existing cultural resources or the development of cultural resources that influence caregiver resilience. Funding This study was supported by funds from the National Institute on Aging Diversity Supplement NIH/NIA 3R01AG044917-02S1 to Dr J. Small. Conflict of Interest None reported. References AARP . ( 2013a). The aging of the baby boom and the growing care gap: A look at future declines in the availability of family caregivers. Retrieved November 12, 2016, from http://www.aarp.org/home-family/caregiving/info-08-2013/the-aging-of-the-baby-boom-and-the-growing-care-gap-AARP-ppi-ltc.html AARP . ( 2013b). Report: Caregivers in crises. Retreived September 1, 2016, from http://states.aarp.org/wp-content/uploads/2013/11/Caregivers-in-Crisis-FINAL.pdf Adamchak, D. J. , Wilson, A. O. , Nyanguru, A. , & Hampson, J . ( 1991). Elderly support and intergenerational transfer in Zimbabwe: An analysis by gender, marital status, and place of residence. The Gerontologist , 4, 505– 513. doi: 10.1093/geront/31.4.505 Google Scholar CrossRef Search ADS   Agyarko, R. 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Aging and HIV-Related Caregiving in Sub-Saharan Africa: A Social Ecological Approach

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Abstract

Abstract Background and Objectives We reviewed the literature on older adults (OAs) who are caring for persons living with HIV/AIDS in sub-Saharan Africa (SSA), with the goal of adapting models of caregiver stress and coping to include culturally relevant and contextually appropriate factors specific to SSA, drawing on both life course and cultural capital theories. Research Design and Methods A systematic literature search found 81 articles published between 1975 and 2016 which were reviewed using a narrative approach. Primary sources of articles included electronic databases and relevant WHO websites. Results The main challenge of caregiving in SSA reflects significant financial constraints, specifically the lack of necessities such as food security, clean water, and access to health care. Caregiving is further complicated in SSA by serial bouts of caring for multiple individuals, including adult children and grandchildren, in the context of high levels of stigma associated with HIV. Factors promoting caregiver resilience included spirituality, bidirectional (reciprocal) caregiving, and collective coping strategies. Discussion and Implications The creation of a theoretical model of caregiving which focuses more broadly on the sociocultural context of caregiving could lead to new ways of developing interventions in low-resources communities. Caregiving, International issues, Stress and coping The confluence of population aging and the HIV/AIDS epidemic in sub-Saharan Africa (SSA) has resulted in a wide range of psychosocial and health impacts that are not fully understood (AVERT, 2015). SSA accounts for 70% of all cases of people living with HIV/AIDS (PLWHA), with prevalence ranging widely across the different countries in the region (UNAIDS, 2015). HIV/AIDS has eroded the working capacity of communities, and affected needed financial and material support to survive (Kang'ethe, 2012; Knodel, Watkins, & VanLandingham, 2002). Thus, many older adults (OAs; 50+) have been forced into primary caregiving roles as younger adults, who would normally provide support to aging parents and their children, died from HIV/AIDS (Mathambo & Gibbs, 2009). Given the contextual nature of older adult (OA) care giving in SSA to PLWHA, it is important to understand the role of context (aging, HIV/AIDS, war, poverty) in the development of effective interventions. In SSA as elsewhere, care is shaped by the culture which informs the dimensions of “good” care, culture-specific approaches to symptoms and illness, and bereavement (Gysels, Pell, Straus, & Pool, 2011). It is critical to address resource deficits for PLWHA and surviving orphans, including lack of basic infrastructure, food insecurity, and poor record keeping (Njororai & Njororai, 2013; Oppong, 2006). Unemployment and industrialization may also play a critical role in the recruitment of OA caregivers, as these forces often lead to urban migration and high prevalence of HIV/AIDS which, in turn, resulted in the creation of orphans and vulnerable children (OVC; Dolbin-MacNab & Yancura, 2017). Patriarchy and the marginalization of women exacerbates care deficits (Schatz & Seeley, 2015). Women, and increasingly OA women, provide most of the informal care in SSA. The emergence of male caregivers who provide both instrumental (financial) and nursing care is reflective of a larger demographic shift related to the feminization of labor in urban centers and the lack of employment for men (Block, 2016; Block, 2014). The main goal of this review article is to extend sociocultural models of stress and coping to a true multilevel model which incorporates the impact of the larger historical context on social institutions, which in turn affect individual level stress and coping practices. We will do this through focusing on the impact of cultural resources on caregiver wellbeing in OAs providing care to persons with HIV/AIDS. Sociocultural Models of Stress and Coping Sociocultural values are important for the caregiving process (Pearlin, Mullan, Semple, & Skaff, 1990). Using Hispanic American caregivers as exemplars, Aranda and Knight (1997) defined culture in terms of a bipolar dimension of individualism and familism. They hypothesized that individuals adhering to individualism would report higher levels of caregiving burden because the provision of care would interfere with the caregiver’s autonomy, whereas those adhering to familism would report lower levels. Surprisingly, this was not supported by their data. Knight and Sayegh (2010) recommended that additional research on ethnic differences in caregiving needed to explore a range of finer-grained dimensions of cultural values that are associated with both positive and negative effects on caregiver health outcomes. Aldwin (2007) suggested that cultural values influence coping resources, including social support and coping strategies, as well as the cognitive appraisal of burden, which might prove to be a fruitful avenue for expanding the model. Following Knight and Sayegh’s (2010) recommendations, we expanded their stress and coping model (see Figure 1). (Knight and Sayegh’s original model is highlighted by a gray background.) The model consists of three levels: the sociohistorical, the intermediate, and the individual contexts. We drew on life course theory (Elder & George, 2016), which posits that individuals’ developmental paths are embedded in and transformed by local and global contexts and events that occur in the historical period and geographical location in which they live. In our model, the sociohistorical level is represented by the current confluence of population aging and the HIV epidemic. In SSA, the role of OA has been transformed in part because the HIV/AIDS epidemic has resulted in over a million deaths among working age adults (15–49), creating a “missing generation” (AVERT, 2015). Figure 1. View largeDownload slide Sociocultural multileveled model of stress and coping. Sayegh and Knight’s model is highlighted in gray. Figure 1. View largeDownload slide Sociocultural multileveled model of stress and coping. Sayegh and Knight’s model is highlighted in gray. The second level of the expanded model in Figure 1 reflects Bourdieu’s theory of cultural capital or resources as the intermediary link between the larger sociohistorical context and immediate context of care (Bourdieu, 1986). Conceptually, culture can be understood to be a resource or capital that can be spent, bartered, saved, discarded, created, or extinguished. Five types of cultural resources have been identified (Bourdieu, 1986; Heckman, 2007). Material capital includes the built environment, including hospitals, housing, transportation, food production, and sanitation systems (Lynch, Smith, Kaplan, & House, 2000; Ralston, 2017), and is a predictor of health and wellbeing among OAs (Ralston, 2017). Financial capital refers to access to tangible assets that can be used to purchase goods and services (Galama, 2015). Cultural capital refers to one’s knowledge base, skill sets, assets, and social status (Bourdieu, 1986). Social capital refers to resources linked to social networks. The amount of social capital depends on the size of network connections and the resources possessed by network members. Human capital refers to an individual’s genetic assets concerning appearance, intelligence, and talents, as well as their health status (Heckman, 2007). Note that culture also includes barriers to resources in these categories, such as some inequalities, health disparities, and social stigma. The third level is the individual level and involves matching the situational demands of caregiving with the cultural resources needed to utilize or create coping strategies in response to these demands (see Aldwin, 2007). The double-headed arrows in the model suggest dynamic, transactional relationships among established cultural resources, caregiving situational demands, caregiver needs, and the resources available to caregivers. When the system is in a state of disequilibrium, caregivers may create new cultural resources to meet these demands. Caregiver resiliency is the ability of caregivers to adapt by using thee cultural resources, and is illustrated by the movement from the intermediate level to the individual level (Aldwin & Igarashi, 2016). Our expanded model differs from Knight and Sayegh’s model in two distinct ways. First, we have expanded their definition of cultural values to refer to resources that can either be pre-existing or newly created to meet ongoing caregiving demands. Secondly, their model focuses on caregiving for patients with dementia, but we believe that this expanded conceptual model may be applicable to a wide range of illnesses and caregiving situations, including HIV-related caregiving. We will apply our conceptual model to the systematic review of the literature on OA caregivers to persons impacted by and/or living with HIV/AIDS in SSA. Methods Approach and Search Strategy We searched both peer-reviewed and gray literature sources for articles published in English between January 1, 1975, and December 31, 2016, on OAs caring for HIV-positive family members in SSA in the following databases: MEDLINE, PsycINFO, Social Sciences Citation Index, CINAHL, Cochrane Library, Africa-Wide: NiPAD, and relevant WHO websites. Articles were included if they met the following inclusion criteria: conducted in SSA; sampled OA caregivers, aged 50 and older; used community samples; and focused on HIV-related impacts. There were no restrictions on sample size or study design. Articles were excluded if they were not available in English. Identified articles from all sources were imported and duplicates removed. Titles and abstracts were read, and if deemed appropriate, the full article was obtained and coded. Organizing the Information Caregivers were defined as adult women or men aged 50+ who are providing care to PLWHA and/or children younger than 18 who may or may not be HIV-positive, but need care because of HIV. Most the articles included in this review had an aspect of caregiver stress/burden, orphan caregiving, or the impacts of caregiving on caregiver health, wellbeing, and finances in the title or abstract. We used a narrative approach similar to Yee and Schultz’s (2000) review of the empirical care giving literature. The diversity in measures used and the heavy reliance on qualitative research made a meta-analysis inadvisable. Several steps were used in organizing this review. Our first step involved summarizing the studies by constructing a table containing the country, sampling strategies, main topical domain, and the salient findings for each study). We considered organizing the articles by country, decade or other time variable (pre-and-post apartheid in South Africa), but there did not appear to be any substantive differences in the reported findings since the late 1990s when this topic first appears, and instead opted to organize it by country and publication date (see Table 1) for heuristic purposes. Table 1. Summary of Sub-Saharan Africa Studies on Older Adults Caregiving for HIV/IADS Family and Friends Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Note: BMI = Body mass index; CG = caregiver; CR = care-recipient; OA = older adult(s); OVC = orphan and vulnerable children; PLWHA = person(s) living with HIV/AIDS. aHealth behavior. bAcceptance of self and life events. cNongovernmental organization. View Large Table 1. Summary of Sub-Saharan Africa Studies on Older Adults Caregiving for HIV/IADS Family and Friends Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Author  Sample and study design  Situational demand  Coping  Caregiver needs  Health impacts  Context/material capital  Financial capital  Social capital  Cultural and human capital  Health resource/ strains  Health outcomes/ behaviors  Multiple countries   Lackey et al., 2011  Qualitative OA CGs and OVC (N = 256)  Inheritance challenge food security  Prevention training  Vulnerable  ▼ Intergenerational relationships  ▼ Intergenerational life skills  ▲ Opportunity cost  ▼ Physical and mental health   Zimmer & Dayton, 2005  Comparative cross-sectional  OAs in extended household    Vulnerable  ▼ Support        Botswana   Shaibu, 2013  Qualitative OAs to OVC (N = 12) age = 60–80  Farm Distance  Spiritualty & resilience  Vulnerable  ▼ Support  Hard accept CG role  ▲ Opportunity cost  ▼ Physical & mental health   Bock & Johnson, 2008  Experimental Women age = 25–49 years (N = 22) & >50 years (N = 17)  OVC discipline    Vulnerable    ▼ Intergenerational life skills  Produce ▼ food     Thupayagale- Tshweneagae, 2008  Qualitative grandmothers to OVC (N = 25)  OVC discipline  Blame on witchcraft bad neighbors  Vulnerable  Stigma  Fail to protect family  Financial, physical & relational stress  Disenfranchised grief Sleepa   Alpasian & Mabutho, 2005  Qualitative (N = 7)      Vulnerable  ▼ Support      ▼ Physical & Mental health   Lindsey et al., 2003  Cross sectional (N = 35)  OAs are dislocated  Spiritualty & resilience  Vulnerable  Stigma  Lack knowledge of HIV/AIDS  Financial, physical, & relational stress  ▼ Mental health. Fasting of food   Drah, 2014  Qualitative (N = 49)  OAs have assets/lack mobility  Spiritualty & resilience  Vulnerable multiple job      Financial, physical stress  ▼ Physical ▲Stress overworkeda   Mwinituo & Mill, 2006  Qualitative (N = 15)  Disrespect by doctors    Vulnerable  ▼ Support high stigma    Hide care work  ▼ Physical & mental health  Kenya   Chepngeno- Langat, 2014  Longitudinal (N = 1,322)  Number of OA CGs ▲ annually by 3%    Saving ▲ likelihood of CG    Age & health ▲ likelihood of CG  Serial CG  ▼ Physical & mental health   Chepngeno- Langat & Evandrou, 2013  Longitudinal (N = 1,489)  Non-CGs older OAs Lack mobility        Age & health ▲ likelihood of CG  Serial CG  For non-CGs ▼ physical & mental health   Ice, Sadruddin, Vagedes, Yogo, & Juma, 2012  Cross sectional Luo CGs age = 60+ (N = 40)  Mostly female CGs        Women ▲ stress than men, Male CGs ▼ stress  Stress  For women, stress ▲ CG & CG intensity but not number of OVC   Ice et al., 2011  Longitudinal age 60+ (N = 689)  Food Security    Vulnerable  Social support → BMI  Age ▼ Nutrition  CG → anthropometric measures  Stress negative → anthropometric measures   Chepngeno- Langat, Madise, Evandrou, & Falkingham, 2011  Cross-sectional N = 1,529)  HIV-CGs were younger    Vulnerable    Gender    Female AIDS CGs have ▲ disability & mobility, male CGs ▼ physical health than non-male CGs   Chepngeno- Langat & Falkingham, et al., 2010  Cross-sectional (N = 1,587)  Most CGs were male    HIV-CGs wealthier than non-CGs    HIV-CGs younger, ▼ schooling & married  Male CGs longer care than female CGs who provide critical care     Skovdal, 2010  Qualitative OA guardians (N = 36), OVC (N = 69)  Bidirectional care between OA & OVC    Vulnerable    OVC are cared for & provide care for OA-CGs       Muga & Onyango-Ouma, 2009  Qualitative/cross sectional (N = 115)  Climate change/increased dependency ratio    Vulnerable  ▼ Support  Intergenerational relationships  Food security     Wangui, 2009  Qualitative 60+ (N = 30)  ▲ Nutritional status, increase land assets  Hired out or gave land to sons  OAs depend on remittances  ▼ Support    ▲ Nutritional OAs Cared for 2-3 OVC  Labor shortage and poor health limited land use   Ice, Zidron, & Juma, 2008  Cross-sectional mean age 73, (N = 287)      Vulnerable  Social support → pain  Age → SF-36 score and health  Grants → low pain, better mental health  Female CGs ▲ health than non-CGs, Male CGs ▼ than non-CG   Oburu, 2005  Cross sectional mothers (N = 115) & OAs (N = 134)  Limited food crop        Age → OVC emotional adjustment score  ▼ Energy, insufficient labor,  OA CGs ▲ stress than biological mothers, stress not → OVC adjustment   Winters et al., 2005  Cross-sectional (N = 103)              No → blood glucose & depression   Juma et al., 2004  Qualitative (N = 84),  Food Security/poor housing, OVC Discipline  Small–scaled farming, pension, loans, spiritualty  Vulnerable    Lack knowledge of HIV/AIDS & care skills  ▲ Opportunity cost. Financial, emotional, and nursing care  ▼ Physical & Mental health Satisfaction for care role   Oburu & Palmérus, 2003  Cross-sectional (N = 249)          Non-literate CGs use coercive discipline    OVCs age & assertive discipline → Total stress   Nyambedha et al., 2003  Qualitative households (N = 1,100)  OVC discipline, Inheritance rights  Used paid labor, small businesses  Vulnerable  ▼ Social support, High social stigma  Tradition of care  ▲ Opportunity cost  Skipped meals & missed sleep to nurse infantsa  Lesotho   Makoae, 2011  Qualitative CGs (N = 21)  High HIV prevalence do not know CR HIV statue        Maintain ritual of feeding    CR food intake linked to CG wellbeing   Littrell et al., 2012  Mixed methods (N = 1,281)      Vulnerable  ▼ Social support  Aged CGs more stable than younger CGs  Must provide financial, emotional and nursing care  OA CGs ▼Physical health & Mental health same for both  Malawi   Sefasi, 2010  Qualitative (N = 116)  Resource depletion    Vulnerable    Knowledge of HIV/ AIDS & care skills  Financial, emotional, & nursing care    Nigeria   Apata et al., 2010  Panel (N = 240)  21% of all OVC loss parents to AIDS  Selling assets  Vulnerable        ▼ Mental health  South Africa   Sidloyi & Bomela, 2016  Qualitative retired women 60+ (N = 15)  Premarital pregnancies, Crime  Loans, friend-ship based networks, small businesses  OAs Casual work, child labor  Social network         Nyirenda et al., 2015  Cross-sectional CGs and non-CGs age 50+ (N = 422)      Vulnerable      Household wealth related to wellbeing  ▲ Alcohol use AIDS death related to OA poor physical health   Dolbin- Magnab, Jarrott, O'Hora, Vrugt, & Erasmus, 2015  Qualitative OA women (N = 75)    Spirituality, loans, OVC grants Social network  OAs Access instrumental support  ▲ Social network      HIV+ OAs ▲ Health than HIV affected OAs   Chazan, 2014  Qualitative OA women (N = 100)        ▼ Social Support Group      OAs enjoyed, & had hope for OVC   Kidman & Thurman, 2014  Longitudinal (N = 726)  Dependency ratio 1:6,Female CGs, Food insecurity    Vulnerable        ▼ Physical & Mental health   Schatz & Gilbert, 2014  Qualitative Women, aged 60+, (N = 30)  Gendered work/roles      Stigma      CG-Burden   Bachman- DeSilva et al., 2013  Longitudinal (N = 4,030)  75% Households had grants, Food insecurity    Vulnerable        ▼ Physical & Mental health   Casale & Wild, 2013  Qualitative  CGs care for average 2.7 OVC, OVC discipline & crime    Vulnerable  ▼ Support         Govender et al, 2012  Longitudinal (N = 616)      Vulnerable  ▼ Support    HIV Wealth depletion  ▼ Physical & Mental health   Schatz & Gilbert, 2012  Qualitative women age 60–75, (N = 30)  Lacking piped water,electricity, climate, OVCdiscipline  Spirituality, traditional medicines  Vulnerable        ▼ Physical & Mental health   Petros, 2012  Cross-sectional OAs in South Africa, (N = 305)  Lacking piped water,electricity, Sanitation, bidirectional care    Vulnerable  Rely on informal support      CG-Fair wellbeing, untreated physical & mental illness   Tamasane & Head, 2012  Cross-sectional (N = 5,254)  1/3rd of children in Kopanong are OVC    Vulnerable  State gate keepers for child grant    Child grants are difficult  CG-rated health as Fair   Petros, 2011  Policy OAs  Lacked basic services    Vulnerable  CG stigma    Care under extreme deprivation  ▼ Physical Health   Casale, 2011  Qualitative older adults    Adversity, resilience, hire out help  Vulnerable child grants are difficult to get  ▼ Support  Traditional healer  ▲ Joy, focus & hope for OVC     Kruger et al., 2011  Cross-sectional rural OAs (N = 134) & urban OAs age = 60+ (N = 196)  Pension main source of income        Age  Health of HIV affected OVC is compromised  Rural OAs had ▲ micronutrient & trace element intake, urban ▲ fat   Ogunmefun et al., 2011  Qualitative 50–75 age (N = 60)    CG secrecy    Verbal & Social stigma      Marginal diets   Schatz et al., 2011  Qualitative Women (N = 21)  Estrange/disconnected households    Vulnerable  ▼ Social Support      ▲ Social isolation Depression   Ardington et al., 2010  Panel data Age 60+, (N = 7,127)  No difference in expenditure pattern CG & non-CG    Pension mitigate consequences of HIV/AIDS  No impact of death of Adult child      CG-Burden & CG-Stress   Boon, James, et al., 2010  Cross-sectional (N = 409)  Female care for average of 4.65 OVC    Income → negative attitude    Communicate with OVC    Expenditure had no impact on Mental &Physical Health   Boon, Ruiter, et al., 2010  Longitudinal isiXhosa (N = 820)  21% of Adult children unemployed, 4.8% of the adult children are HIV+, OAs care for a average of 4.6 OVC    Vulnerable  ▼ Social Support    Intervention  Program ▲ CG ability to relax   Raniga & Simpson, 2010  Qualitative OA (N = 15)  Pension stabilized family  Spirituality    ▲ Social supports    Adult death ▼ income  ▼ Physical & Mental health   Munthree & Maharaj, 2010  Mixed methods men & women (N = 974)  25% of CGs care > 3 OVC, Females are primary CGs    Vulnerable      Adult death ▼ income  CG-burden/exhaustion   Boon et al., 2009  Cross-sectional isiXhosa speaking CGs (N=202)  50% of OAs have no income & care for 4.97 OVC    Vulnerable  Completion ▲ attitudes for PLWHA  Completion ▲ CG attitudes, norms & care    ▼ Physical & Mental health   Hlabyago & Ogunbanjo, 2009  Qualitative age 50+ (N = 9)  OVC discipline    Vulnerable  ▼ Support social & services  CG painful    Mental & physical health/fear risk for HIV   Nyasni, Sterberg, & Smith, 2009  Qualitative age 50+, (N = 45)  OVC discipline    Vulnerable  ▼ Support social  Emotional support to OVC  Intergenerational Disharmony  CG burden/Physical health   Hosegood, Preston, Busza, Moitse, & Timaeus, 2007  Qualitative CG age 50+ and OVC 15+ (N = 12)  OA men were more likely to be married/OA lived in extended families    Vulnerable  AIDS death 20% of household    Adult death ▼ income  Mental Health   Schatz, 2007  Qualitative OAs age >59 (N = 30)  OA lived in extended families    Vulnerable  ▼ Family support  Provide emotional support to OVC  Adult death ▼ income     Hosegood, & Timaeus, 2006  Cross-sectional (N=10,612)  50% of household experience a death of prime-age adult    Vulnerable  Stigma & isolation  OA care expected  Adult death ▼ income     Ogunmefun & Schatz, 2009  Cross-sectional female CGs (N = 60)  OA women are becoming CGs  Invested in insurance/credit  HIV households vulnerable  Extended family supported    OAs pay for all care to PLWHA     Reddy, James, Esu-Williams, & Fisher, 2005  Qualitative (N = 89)  Pensions are used for household needs, OVC discipline    Vulnerable  Community social support    Must carry out multiple parenting roles  CG is emotionally & physically demanding  Tanzania   de Klerk, 2011  Qualitative OA caregivers  Data collected before roll-out of antiretroviral therapy      CRs are hidden to keep social support  Concealment means good parenting & loving care    ▲ Mental health   Dayton & Ainsworth, 2004  Cross-sectional Age = 50+ (N = 757)  OA are not mobile in households Death of prime- age adult → presence of OAs    Healthy household 2× ▲ gainful activity rates,      42% of deaths were among prime-age adult  Prime-age adult death → ▲ BMI   Ainsworth & Dayton, 2003  Cross-sectional Age = 50+ (N = 1512)  56% of OAs have no durable assets, 67% of deaths attributed to AIDS    Vulnerable Adult death ▼ income    BMI ▲ women than men  42% of deaths were among prime-age adult  Household wealth ▲ BMI for OAs OVC in household ▼ → BMI  Togo   Moore, 2007  Qualitative age = 50+, (N = 7)    Emotional coping, sought professional help  Adult death ▼ income  Adult death ▼ social support  OAs felt too old for CG  OAs pay for all care to PLWHA & OVC  Accepting death of adult child, CG burden for OVC   Moore & Henry, 2005  Mixed Method OAs (N = 50)    Condoms, stopping sexual activity, monogamy  Vulnerable Adult death ▼ income  ▼ social support & isolation  Do not believe HIV care is risky  Need affordable drugs &foods  CG burden for OVC  Uganda   Rutakumwa et al., 2015  Qualitative OAs (N = 40) dyads  Subsistence food production    Vulnerable  ▼Social support    Financial, physical & relational stress  ▼ Physical & Mental health &bidirectional CG   Seruwagi, 2014  Qualitative (N = 129)  Bidirectional caregiving between CGs and OVC        OAs support early marriage  OAs provide instrumental s upport for education  ▼ Physical & Mental health &bidirectional CG   Kasedde et al., 2014  Qualitative OA (N = 61)  Reciprocity Cultural intergenerational exchange  Preparing OVC for OA’s death  Vulnerable  ▼ social support & Stigma  Use of traditional medicine  Timing of CG Financial & relational stress     Mugisha et al., 2013  Cross-sectional, (N = 510)      CG work → financial & physical support  Women → financial support than men  Women care for OVC & provide → care than men    CG work, poverty, poor health HIV → CG burden   Kamya & Poindexter, 2009  Qualitative OA CGs (N = 11)  HIV/AIDS deaths, war and famine  Spirituality/inner resiliency  Vulnerable      Logistics of care & money  Stress, fear & poverty   Nankwango, Neema, & Phillips, 2009  Qualitative (N=215)  58% of population has lost someone to AIDS  Social support, professional help, faith    ▼ social support & Stigma  Lack of education about HIV  Burden of OVC care is on rural OAs     Ssengonzi, 2009  Qualitative (N = 27)      PLWHA’s finances → OA CG  ▼ social support & Stigma  Women provide care mostly spouse    ▼ Physical & Mental health   Ssengonzi, 2007  Qualitative N = 20,  Food insecurity  Food cultivation  Vulnerable  ▼ social support & Stigma  Women provide care mostly spouse  Financial, physical & relational stress  ▼ Physical & Mental health   Kakooza & Kimuna, 2005  Cross-sectional OA, age 50+ (N = 300)      Vulnerable  ▼ social support & Stigma    Financial, physical & relational stress  ▼ Physical & Mental health Balance dieta  Zimbabwe                ▼ Physical & Mental health   Zvinavashe, Mukombwe, Mulkona, & Haruzivishe, 2015  Qualitative OVC- CGs (N = 30)  In adequate housing  Seek help from donations, sold surplus goods  Vulnerable  ▼ social support      No physical & Mental health problems   Mhaka- Mutepfa et al., 2015  Cross-sectional Mean = 62.4 (N = 327)  Most have access to care Material capital not → ASLb score      Social support → ASL score  Age → with resilience & ASL    Urban OAs, physical & Mental health → ASL   Skovdal et al., 2011  Qualitative Nurses (N = 25) OAs, (N = 8)  Food needs are being met via NGOsc Lack of transportation    Vulnerable  ▼ social support  Poor health literacy  Financial, physical & care stress  ▼ Physical & Mental health   Mudavanhu, Segalo, & Fourie, 2008  Qualitative Age = 50 + 6 (N = 12)  Climate instability Food insecurity  Seek help from donations, grants  Vulnerable      Financial, physical & care stress  ▼ Physical & Mental health   Agyarko et al., 2002    Food insecurity, Community violence    Vulnerable  Stigma  Fear of contracting HIV  Financial, physical & care stress  ▼ Physical & Mental health   Bindura- Mutangandura, 2001  Qualitative mean 50+ (N = 20)    Resource reallocation join burial societies  Adult child death ▼ Vulnerable  Adult child death ▼ social support    Financial, physical & care stress  ▼ Physical & Mental health   Mupedziswa, 1997  Policy study  Climate instability Food Insecurity Foreign debt  Use pension  Vulnerable  Adult child death ▼ social support    Need for healthcare, food, and shelter    Note: BMI = Body mass index; CG = caregiver; CR = care-recipient; OA = older adult(s); OVC = orphan and vulnerable children; PLWHA = person(s) living with HIV/AIDS. aHealth behavior. bAcceptance of self and life events. cNongovernmental organization. View Large We grouped these items into the categories defined by our theoretical model to illustrate the importance of cultural resources on informal caregiving. Finally, where appropriate, we noted examples of health outcomes across the three broad domains of health resource strains, health behaviors, and health outcomes. Results A total of 122 articles were identified from the databases, out of which a total of 81 met all the selection criteria and were used in the study. Articles were excluded because the topic did not include caregivers (n = 17), the caregiver was too young (n = 9), the study was not based in SSA (n = 11), or did not meet other criteria (n = 3). Out of the 81 reviewed articles, most were situated in South Africa (n = 31), followed by Kenya (n = 16), and Uganda (n = 9), Zimbabwe (n = 7), with the remaining studies in Botswana (n = 5), Ghana (n = 2), Lesotho (n = 1), Malawi (n = 2), Nigeria (n = 1), Tanzania (n = 3), and Togo (n = 2). Two cross-sectional studies on OA caregivers examined five or more countries at once. The articles described a variety of methods to collect data including, qualitative data collection (44%), cross-sectional and longitudinal quantitative studies (51%), and mixed-methods research studies (5%). Situational Demands The deaths of prime-age adults have altered household composition and access to resources (Adamchak, Wilson, Nyanguru, & Hampson, 1991; Agyarko, Madzingira, Mupedziswa, Mujuru, & Kanyowa, 2002; Ainsworth & Dayton, 2003; Cohen & Menken, 2006). The articles detailed the poor infrastructure, such as the lack hospitals, medications, access to land, irrigation and modern farming techniques, food distribution, and transportation, as well as widespread unemployment, food insecurity, and climate change. This impacts OA caregivers’ ability to provide safe and effective care to PLWHA and to OVC (Ainsworth & Dayton, 2003; Juma, Okeyo, & Kidenda, 2004; Muga & Onyango-Ouma, 2009). For example, in Tanzania, early publications reported that social safety nets were compromised (Kaijage, 1997), hospitals were overwhelmed (Uys & Cameron, 2003), and food insecurity was commonplace (United Republic of Tanzania, 2006). Recent reports from Tanzania suggest that little has changed. HIV-related stigma and discrimination, stress, and care burden continue to challenge resources for caregiving (de Klerk, 2011; Pallangyo & Mayers, 2009). AIDS-related deaths have resulted in the creation of 12-million orphans who have largely been absorbed into extended family networks comprised of OAs (Hlabyago & Ogunbanjo, 2009). In most countries in SSA, the extended family, primarily grandparents, care for a large number of OVC (HelpAge International, 2008; Monasch & Boerma, 2004). In national household surveys conducted in 40 countries, only 13 of the countries included information on OA caregivers (Monasch & Boerma, 2004). In those 13 countries, between 24% and 64% of OAs were fostering OVC affected by HIV/AIDS. In Malawi, OAs cared for nearly half (46%) of orphans who have lost both parents. Despite the relatively low prevalence of HIV/AIDS in Kenya, the percentage of OAs providing care increased from 11% in 2006 to 14% by 2014 (Chepngeno-Langat, 2014). In Namibia, the proportion of orphans being cared for by grandparents rose from 44% in 1992 to 61% in 2000 (UNICEF, 2003). In Zimbabwe, South Africa, and Namibia, 60% of AIDS orphans lived with OA caregivers (Zimmer & Dayton, 2005). Caregiving for OVC has some positive aspects. In Kenya, OVC in the household was associated with better health outcomes for men (Ice, Juma, & Yogo, 2008). In Botswana, a country with the second highest prevalence of HIV/AIDS in the world (17.6%), both children and OAs provide bidirectional care (Lindsey, Hirschfeld, Tiou, & Neube, 2003). Similar patterns of bidirectional care were reported in Kenya and South Africa (Petros, 2011, 2012; Skovdal, 2010). Often, OAs are receiving care for non-HIV or HIV-related health issues or personal care (Nyirenda, Evandrou, Mutevedzi, Hosegood, & Falkingham, 2015). In SSA, OVC often do necessary chores, such as hauling water, tending animals, and so on, which helps both to fill in the labor gap caused by parental death and helps the grandparent’s household economy (Sidloyi & Bomela, 2016; Skovdal, 2010). This care work by OVC is not purely instrumental. In Uganda, the care work for OA caregivers was described as compassionate, highly desired, and loving (Rutakumwa et al. 2015; Seruwagi 2014). Food insecurity, reported in most of the reviewed articles, is perhaps one of the most unanticipated effects of the HIV/AIDS epidemic. This stems in part from the loss of working age adults, access to land, inheritance laws, and an overall of loss of productivity due to poverty (Agyarko et al., 2002; Mwanyangala, Mayombana, & Urassa, 2010; Pallangyo & Mayers, 2009), time spent caregiving, lack of knowledge of modern farming techniques, increased household size, aging, and chronic health problems (Nyirenda et al., 2015; Oburu, 2005; Wangui, 2009). OAs who cared for very young children seem to be particularly burdened (Shaibu, 2013). In summary, the HIV/AIDS literature has largely focused on the impacts of caring for OVC rather than OAs caring for both adult children and grandchildren. Research is needed on the influence of HIV-related caregiving responsibilities versus other types of informal care and how care recipients are affected when an established caregiver experiences a decline in health or functional status. Caregiver Needs Caregiver needs reflect the range of resources required for support. Included is the availability of resources that directly impact caregiver performance in assistance with activities of daily living (ADL), and instrumental activities of daily living (IADL), such as the access to financial capital, social support (social capital), and caregiving know how (cultural capital). Financial Capital The main source of income for caregivers varied by country. In South Africa, the majority of OAs depend on the old-age pensions and cottage industries, e.g., selling fruit, milling grain, or providing other nondurable goods and services (Bachman-DeSilva et al., 2013). The impact of public transfers are considerable; a Cape Town study found no differences in expenditure patterns between households with orphans, AIDS-related deaths, and other OA households (Ardington et al., 2010). Household subsidies did initially promote stabilization of households in SSA (Raniga & Simpson, 2010). However, the subsidies were not enough and subsequent studies reported that OAs were financially worse off after providing care to a family member with HIV (Bachman-DeSilva et al., 2013; Casale, 2015; Casale & Wild, 2013; Cohen et al., 2015; Kidman & Thurman, 2014). Many SSA countries do not have broad pension coverage, and poverty consistently impinges on cultural resources throughout the region. Reasons for economic insecurity center around six recurring themes. First, caregiving duties prevented engaging in income-generating activities (Chazan, 2008; Juma et al., 2004; Shaibu, 2013), and second, there were fewer family members available to farm and tend cattle (Lindsey et al., 2003; Wangui, 2009). Third, repeated bouts of caregiving depleted household resources (Chepngeno-Langat, 2014), often resulting in the fourth problem, poor health. Fifth, what few government grants exist are often inconsistent, insufficient, and nonaccessible (Bachanas et al., 2001; Hlabyago & Ogunbanjo, 2009; Petros, 2012; Tamasane & Head, 2012). Finally, HIV-related caregiving resulted in a lack of support from surviving sons and daughters, as well as inheritance inequalities among male and female family relatives. Thus, there are multiple pathways to poverty among older caregivers. Social Capital Despite the large literature on caregiving and PLWHA in high-income countries (HICs; Prachkul & Grant, 2003), most studies only examined instrumental social support and stigma. Several SSA studies reported that OA caregivers continue to experience a shortage of informal supports from family, friends, or neighbors (Alpasian & Mabutho, 2005; Boon, Ruiter, et al., 2010; Nyambedha, 2007; Nyambedha, Wandibba, & Aagaard-Hansen, 2003). Most OAs in South Africa (86%) reported that they were solely responsible for providing basic need for dependents (Boon, Ruiter, et al., 2010). In Malawi, only 31% of OAs were dependent on adult children for help (Sefasi, 2010). In Kenya, social support was linked to increased pain and higher BMI scores (Ice, Heh, Yogo, & Juma, 2011; Ice et al., 2008; Wangui, 2009). Instrumental support from nonfamily sources was equally strained. Several studies reported that OA caregivers were not treated with respect by governmental official and by hospital staff, including doctors (Hlabyago & Ogunbanjo, 2009; Mwinituo & Mill, 2006; Tamasane & Head, 2012). OA caregivers experienced many forms of stigma. In Botswana, OAs reported a sense of loneliness and isolation and that stigma was experienced by both caregivers for PLWHA and other chronic diseases (Lindsey et al., 2003). Caregivers in South Africa reported verbal, voyeuristic, and physical stigma (Hosegood & Timaeus, 2006; Lindsey et al., 2003; Ogunmefun, Gilbert, & Schatz, 2011). In Ghana, OA caregivers go to great lengths to hide the HIV status of care recipients as well as their caregiving activities, resulting in isolation of both the PLWHA and the caregiver (Mwinituo & Mill, 2006). Coping Strategies Studies of coping mainly addressed financial strategies and religious/spiritual strategies. OA caregivers coped with financial strain by using their knowledge and social networks to access old-age and foster-care grants, as well as their saving accounts (Ardington et al., 2010). In Kenya, OA caregivers engaged in small-scale farming and the selling of assets to meet the ongoing care needs of PLWHA and funeral costs (Wangui, 2009). There is some evidence that OAs in South Africa use a revolving pool of microcredit as a source of income (Lackey, Clacherty, Martin, & Hillier, 2011; Ogunmefun & Schatz, 2009; Schatz & Ogunmefun, 2007). Additional coping strategies included: applying for food grants, carefully managing income, investing in funeral insurance and credit programs, and creating associations to form social support networks (Casale, 2011; Chazan, 2008, 2014; Juma et al., 2004). Several studies reported the use of spirituality as a coping mechanism (Drah, 2014; Shaibu, 2013). In South Africa, caregivers reported talking to their pastor, congregants, and praying to God (Chazan, 2008). Alternately, silence and concealment of AIDS illness was a coping mechanism identified in South Africa to protect and honor individuals affected by HIV/AIDS (de Klerk, 2011). Health Impacts Health Resource Strains There are several unusual characteristics of HIV-related caregiving in SSA. The first is serial caregiving—many OAs care for one adult child, and then another—either concurrently or sequentially, as well as their offspring. In Kenya, 10% of noncaregiving OAs in a household transitioned into caregiving and 50% of these caregivers were providing care transitioned to noncaregiving status (Chepngeno-Langat & Evandrou, 2013). A second feature is the number of care-recipients, which are generally not analyzed with regard to caregiver health outcomes or asset dissolution. Caregiving is associated with high opportunity costs where OAs must forgo gainful opportunities to provide care (Nyambedha, Wandibba, & Aagaard-Hansen, 2001). Health Behaviors Health behaviors were only examined by two studies. In the first, OA caregivers reported foregoing meals, restricting their food intake, or working extra jobs to purchase the care-recipient’s preferred food (Kruger, Lekalakalamokgela, & Wentzel-Viljoen, 2011). The second study found that alcohol abuse was problematic for OA caregivers in South Africa (Sidloyi & Bomela, 2016). Health Outcomes Grandparents are grieving both for their adult children and report stress in caregiving for grandchildren. In Botswana, OAs had “disenfranchised” grief: they had to hide their own pain of losing adult children because they had to serve as a source of strength to the surviving grandchildren (Thupayagale-Tshweneagae, 2008). Grandmother caregivers in Botswana, Togo, and Uganda reported that they felt depressed and isolated, with a loss of control when grandchildren were unruly and disrespectful (Kamya & Poindexter, 2009; Moore, 2007; Thupayagale-Tshweneagae, 2008). Over half (57%) of Kenyan caregivers reported a poor quality of life and 74% reported that caregiving had a large impact on their lives (Lindsey et al., 2003). Kenyan caregivers of HIV-positive kin had poorer self-reported health compared to other types of caregivers. Men reported worse health than women and new caregivers were more likely to report having a major health problem compared with those who had never provided care (Chepngeno-Langat, 2014). Thus, the majority of the studies find impaired mental and physical health among caregivers, perhaps due to their greater poverty and age. Discussion The literature on OA caregiving in SSA is fragmented across several disciplines. Despite the more robust literature on HIV-related caregiving in HICs, much less is known about OA caregivers providing HIV-related care to adult children and grandchildren in SSA. This is important because, in many ways, the situation in SSA presages a dilemma that HICs will be facing in the next few decades—namely, many OAs will be requiring care and there will be too few caregivers (AARP, 2013a, 2013b). We found that OA caregivers in SSA face a range of challenges that can be framed by the sociohistorical context of population aging and AIDS. Further, our adapted cultural resources model emphasizes the collective nature of both the stressors and adaptive strategies. Most of the articles reviewed focused on material and economic resources, with comparatively fewer about psychosocial resources such as nonfinancial social support and coping in the SSA context. Although access to “public goods” is critical to caregiver wellbeing, it does little to address contextual factors such as, inheritance rights, intergenerational conflict, HIV-stigma, and rising dependency ratios (Lackey et al., 2011; Ralston, 2017). Another topic not addressed in the reviewed literature was related to the development of post-colonial migrant labor patterns (Camlin et al., 2010). However, the relationship between migration and AIDS is complex, and most individuals move to urban centers for economic benefits. Whether this applies to OA caregivers is unknown. Our multileveled model allows for the capturing of the social-cultural context of caregiving in SSA (population aging and HIV/AIDS pandemic). Studies reviewed consistently reported resource constraints that framed the situational demands of care including: lack of material capital (safe housing, roads, and transportation); lack of inheritance rights; and lack of food security (Ice et al., 2011; Lackey et al., 2011). These stressors were further augmented by the necessity of needing to care for multiple family members, either serially or at the same time (Chepngeno-Langat, 2014; Zimmer et al., 2005). A significant finding was that the bidirectionality of caregiving was often emphasized. Grandchildren were not only the recipients of care, but they also provided much needed household and farm labor which enhanced their grandparents’ ability to provide care (Kasedde et al., 2014; Petros, 2012; Skovdal, 2010). The care by OVC was not purely instrumental (e.g., running chores). OAs draw strength from their OVC and attach a great deal of importance to the quality of their relationships (Seruwagi, 2014). Third, at the individual level, the use of cultural resources was linked to a range of coping strategies, such as religious/spiritual coping, which is a very important resource. However, the collective nature of some of the coping strategies allowed for leveraging in resource-poor environments. Villagers reported communal strategies for financial and nutritional shortfalls, as well as for accessing often-distant medical care and meet cultural demand of funeral costs (Njororai & Njororai, 2013). The relationship between caregiving and caregiver physical wellbeing was more complex. Several studies reported poor health outcomes, but a few studies reporting positive health outcomes. Some of this may be due reverse causality—younger and healthier individuals may take up caregiving duties. However, there is some evidence that having a purpose in life may prove beneficial for older caregiver’s health (Casale, 2015). The SSA grandparents are often literally the only factor preventing complete destitution of their households, which provides a powerful incentive for maintaining functional health. Despite the resource-poor environment in SSA, many OA caregivers nonetheless exhibited resilience. They drew on their religious/spirituality, their sense of purpose, and their embeddedness in the communities. Despite social stigma, they often utilized collective strategies. Finally, this review emphasized the importance of OAs—in holding together their families and cultures in the face of an overwhelming pandemic and economic pressures. Conclusion and Future Directions The current body of evidence uncovered in this literature review partially supports our adapted conceptual model. This model allows for an integrated understanding of the stress and coping processes stemming from the wider cultural context. By identifying cultural resources and the collective nature of coping and adaptation in a resource-poor environment, our model provides a framework for caregiver intervention that is not solely focused on the individual, but recognizes the importance of targeting community-level efforts in interventions. Bidirectional caregiving is emerging as an important construct (Nagpal, Heid, Zarit, & Whitlatch, 2015). We need more research understanding the dynamic transactions between family members, friends, and the larger community to understand the resources that can be both drawn on and created during stressful situations. Next steps for research in this field should include the identification of processes that fortify existing cultural resources or the development of cultural resources that influence caregiver resilience. Funding This study was supported by funds from the National Institute on Aging Diversity Supplement NIH/NIA 3R01AG044917-02S1 to Dr J. Small. Conflict of Interest None reported. References AARP . ( 2013a). The aging of the baby boom and the growing care gap: A look at future declines in the availability of family caregivers. Retrieved November 12, 2016, from http://www.aarp.org/home-family/caregiving/info-08-2013/the-aging-of-the-baby-boom-and-the-growing-care-gap-AARP-ppi-ltc.html AARP . ( 2013b). Report: Caregivers in crises. Retreived September 1, 2016, from http://states.aarp.org/wp-content/uploads/2013/11/Caregivers-in-Crisis-FINAL.pdf Adamchak, D. J. , Wilson, A. O. , Nyanguru, A. , & Hampson, J . ( 1991). Elderly support and intergenerational transfer in Zimbabwe: An analysis by gender, marital status, and place of residence. The Gerontologist , 4, 505– 513. doi: 10.1093/geront/31.4.505 Google Scholar CrossRef Search ADS   Agyarko, R. 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