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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 1  |  Page : 40-46

Determinants of psychosocial disorders among caregivers of HIV-infected children in Enugu, Southeast Nigeria


1 Department of Paediatrics, Federal Medical Centre, Umuahia, Nigeria
2 Department of Paediatrics, University of Nigeria, Enugu Campus, Enugu, Nigeria; Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria

Date of Web Publication1-Aug-2019

Correspondence Address:
Dr. Ikechukwu F Ogbonna
Department of Paediatrics, Federal Medical Centre, Umuahia
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_7_19

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  Abstract 

Background: Human immunodeficiency virus (HIV) infection is a global pandemic. Nigeria has the highest burden of pediatric HIV worldwide. HIV-infected children and their caregivers are predisposed to significant psychosocial disorder. This disorder may be provoked by some risk factors. Aim: To determine the factors responsible for psychosocial disorders among the caregivers of HIV-infected children in Enugu, Southeast Nigeria. Materials and Methods: This was a hospital-based comparative study. Participants who met the inclusion criteria were enrolled consecutively. The HIV status and other sociodemographic variables of the caregivers were obtained. General Health Questionnaire (28-item version) was used to assess their psychosocial status. Thereafter, the association between psychosocial disorders and their sociodemographic variables was ascertained. Results: A total of 154 caregivers of HIV-infected children (subjects) and 154 caregivers of HIV-negative children (controls) were enrolled in this study. The prevalence of psychosocial disorders among the subjects was 39% compared to that of 2.6% among the controls. The determinants of psychosocial disorders among these subjects were the child’s age group of 2–4 years (P < 0.001, odds ratio [OR] = 3.60), caregiver’s gender (P < 0.001, OR = 13.48), lower socioeconomic class (P < 0.001, OR = 37.14), divorced caregiver (P = 0.03, OR = 10.33), death of a spouse (P < 0.001, OR = 8.84), additional HIV-infected family member (P = 0.015, OR = 2.56), and unsupportive spouse (P = 0.027, OR = 2.113). Conclusion: The determinants of psychosocial disorders among the caregivers of HIV-infected children were the age of the HIV-infected child, female caregivers, lower socioeconomic class, marital status, additional HIV-infected family member, and lack of spouse support.

Keywords: Caregivers, children, human immunodeficiency virus, Nigeria, psychosocial disorders


How to cite this article:
Ogbonna IF, Ojinnaka NC, Emodi IJ, Ikefuna NA. Determinants of psychosocial disorders among caregivers of HIV-infected children in Enugu, Southeast Nigeria. Int J Med Health Dev 2019;24:40-6

How to cite this URL:
Ogbonna IF, Ojinnaka NC, Emodi IJ, Ikefuna NA. Determinants of psychosocial disorders among caregivers of HIV-infected children in Enugu, Southeast Nigeria. Int J Med Health Dev [serial online] 2019 [cited 2019 Oct 22];24:40-6. Available from: http://www.ijmhdev.com/text.asp?2019/24/1/40/263548




  Introduction Top


Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome is a global health challenge and majority of HIV-infected individuals live in sub-Saharan Africa.[1],[2] Nigeria, a sub-Saharan country, has the highest burden of pediatric HIV worldwide.[3] These HIV-infected children require lifelong medical attention and frequent hospital visits. The implication is the limitation of the social life of their caregivers with increased daily burden of caring for the HIV-infected children.[4] This is burdensome to their caregivers and may precipitate psychosocial disorders.[4],[5] Unfortunately, majority of these caregivers are also HIV infected,[6] thus, further affecting their overall functioning and lifestyle.[4] Their psychosocial disorders may also emanate from the frequent hospital visits and hospitalizations, chronic medication intake, poverty, stigma and discrimination, increasing financial burden, or directly from the disease.[4]

Studies have shown high prevalence of psychosocial disorders among the caregivers of HIV-infected children.[4],[6] For instance, the prevalence was as high as 23.1% in a study in Cuba.[7] A similar study in Kenya reported a prevalence rate of 29.5% and 64.5% for anxiety and depression, respectively.[8] Studies have also shown that sociodemographic factors, such as poverty, caregivers’ age, and gender, were possible determinants of these high prevalence.[7],[9],[10],[11],[12],[13] For example, Santiesteban et al.[7] observed that in Cuba, 92.3% of the caregivers (of HIV-infected children) with psychosocial disorders were females. Similar findings were also noted by Wainaina[8] and Lv et al.[14] in Kenya and China, respectively. In addition, a high proportion of these caregivers, as observed by some authors,[7],[8],[12],[13] belonged to the lower socioeconomic class, had poor spouse support, or had lost a spouse to death.

Despite the high prevalence of psychosocial disorders and documented risk factors among these caregivers, to the best of our knowledge, there have not been any of such studies in Enugu, Southeast Nigeria. We therefore hypothesized that sociodemographic factors (such as caregivers’ age and gender) will determine the presence of psychosocial disorders among the caregivers of HIV-infected children in Enugu. This study aimed to determine the factors responsible for psychosocial disorders among the caregivers of HIV-infected children in Enugu, Southeast Nigeria.


  Materials and Methods Top


Study design

This was a hospital-based comparative study involving caregivers of HIV-infected children who served as “subjects” and caregivers of HIV-negative children who served as “controls.”

Study site

The research was conducted from March 2014 to November 2014 at the pediatric HIV clinic of a teaching hospital in Enugu, Southeast Nigeria. The clinic provides treatment, care, and support for HIV-infected and HIV-exposed children.

Study population

The subjects were the primary caregivers of HIV-infected children aged between 2 and 15 years who were enrolled and receiving treatment in the pediatric HIV clinic and whose HIV status was confirmed at the time of enrollment. The control group consisted of HIV-negative caregivers of HIV-negative children who were attending the children’s outpatient clinic of the teaching hospital for acute illnesses or medical examinations such as medical certificate of fitness. In this study, a primary caregiver was defined as the person with the most responsibility of providing care and support to the HIV-infected child.[15],[16]

Sample size determination

The sample size was statistically determined using the statistical formula for comparison of proportions in two equally sized groups.[17]

Inclusion and exclusion criteria

Primary caregivers whose children’s HIV status is not known and who have children with other chronic disorders (such as epilepsy, cerebral palsy, or sickle cell anemia) under their care were excluded from the study.

Recruitment of study participants

The children in the control group underwent HIV counseling and testing using the HIV testing national algorithm. This was to ascertain their HIV-negative status. Thereafter, they were matched for age and gender with the HIV-infected children before the recruitment of their caregivers.

The sociodemographic data of the caregivers were obtained by the researchers using a questionnaire designed for this study, whereas their socioeconomic class was determined using the social classification by Oyedeji.[18] In Oyedeji’s classification, the educational level and the occupation of the caregivers were scored and the average of these scores, to the nearest whole number, was noted. This was graded from one to five, with class one representing the highest social class and class five representing the lowest social class. For the purpose of this study, classes one and two of the Oyedeji classification represented the upper social class (social class 1), class three represented the middle class (social class 2), whereas classes four and five represented the lower social class (social class 3). This method of subclassification of Oyedeji’s classification has been used by other researchers.[19],[20],[21]

The prevalence of psychosocial disorders among the caregivers was assessed using a self-administered General Health Questionnaire: 28-item version (GHQ-28), proposed by Goldberg.[22] It has been validated, translated into our local languages, and widely used in Nigeria in the assessment of psychosocial disorders.[23],[24],[25] Thus, GHQ-28 has been used in Nigeria to assess the prevalence of psychosocial disorders in HIV infection.[23],[24],[25] It consists of four domains, each containing seven items. The first two responses on each domain attracted a score of zero, whereas the last two responses attracted a score of one. A cumulative score (of all the domains) of five and above on the GHQ-28 indicated the presence of a psychosocial disorder. The caregivers were allowed to complete the questionnaires on their own; however, the questionnaires were readout to nonliterate caregivers and their responses were recorded.

Pilot study

A pilot study was performed on 10 subjects and 10 controls. Nine of the subjects and the entire control group answered the questions correctly. The caregivers who partook in this study were excluded from the main study.

Ethical approval and consent

Ethical approval by the health research and ethics committee of the teaching hospital was obtained before the commencement of this research. Details of the study were explained to the caregivers and only those who gave their consent were enrolled for the study. An informed consent form was filled (or thumbprinted) by the consenting caregivers.

Data analysis

The data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 19 (SPSS, Chicago, Illinois). Descriptive statistics such as mean values and standard deviations were used to summarize the mean age of the caregivers, whereas frequencies and percentages were used to summarize the gender distribution and socioeconomic classes of the caregivers. The outcome variables for the caregivers of HIV-infected children were compared with those of the controls and analyzed for statistical significance. Student’s t-test was used to test for significance difference between the mean ages of the subjects and controls. Chi-square test was used to test for significant difference between the gender distribution and the socioeconomic classes of the subjects and controls. Logistic regression analysis was used to test for association between the prevalence of psychosocial disorders of the subjects and controls. Logistic regression analysis was also used to test the association between the prevalence of psychosocial disorders and the sociodemographic variables of the subjects. P values less than 0.05 were regarded as significant and all the reported P values were two sided.


  Results Top


The subjects were 154 caregivers of HIV-infected children aged between 2 and 15 years, whereas 154 caregivers of HIV-negative, apparently, healthy children, served as controls. The mean age of the caregivers of HIV-infected children was 38.98 ± 9.96 years, whereas that of the controls was 38.29 ± 8.53 years. [Table 1] shows the comparison of the mean age, gender distribution, and the socioeconomic classes of the caregivers of HIV-infected children (subjects) and the caregivers of HIV-negative children (the control group).
Table 1: Comparison of the mean age, gender distribution, and socioeconomic classes of the caregivers of HIV-infected and caregivers of HIV-negative children

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Of the 154 caregivers of HIV-infected children who participated in this study, 60 representing a prevalence of 39% compared to four (2.6%) of the 154 controls had GHQ scores in the psychosocial range (GHQ ≥ 5). The difference was statistically significant (P < 0.001, odds ratio [OR] = 23.936). [Table 2] presents the prevalence of psychosocial disorders among the caregivers of HIV-infected and HIV-negative children.
Table 2: Prevalence of psychosocial disorders among the caregivers of HIV-infected and caregivers of HIV-negative children

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Among the 60 subjects with psychosocial disorders, 44 (73.3%) had an existing HIV infection. However, no significant difference was observed in the prevalence of psychosocial disorders between HIV-positive and HIV-negative subjects (χ2 = 0.594, df = 1, P = 0.441). [Table 3] shows the prevalence of psychosocial disorders among the HIV-positive and HIV-negative subjects. In this study, 48.3% of the subjects with psychosocial disorders belonged to the age group of 30–39 years, 95% were females, 61.7% had HIV-infected children aged 2–4 years, 86.7% belonged to the lower socioeconomic class, and 48.3% had lost a spouse to death. Also, 85% and 64.9% of these subjects with psychosocial disorders had other HIV-infected family members and unsupportive spouse, respectively. These findings were statistically significant, except for the age of the subjects (subject’s age: P > 0.005; children’s age group of 2–4 years: P < 0.001, OR = 3.60; female gender: P < 0.001, OR = 13.48; lower socioeconomic class: P < 0.001, OR = 37.14; widow/widower: P < 0.001, OR = 8.84; other HIV-infected family members: P = 0.015, OR = 2.56; and unsupportive partner: P = 0.027, OR = 2.113). [Table 4] describes the relationship between sociodemographic variables and psychosocial disorders among the subjects.
Table 3: Prevalence of psychosocial disorder among HIV-positive and HIV-negative caregivers of the HIV-infected children

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,
Table 4: Relationship between sociodemographic factors and psychosocial disorders among the caregivers of the HIV-infected children

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  Discussion Top


This study showed that the prevalence of psychosocial disorders among the caregivers of HIV-infected children is 39%, which compares favorably with a prevalence of 34% documented by Bachanas et al.[26] in Atlanta but higher than 27% and 23.1% as reported by New et al.[27] in Washington and Santiesteban et al.[7] in Cuba, respectively. No data were available on the prevalence of psychosocial disorders from Africa, except from the study by Wainaina[8] in Kenya, to enable comparison. However, Wainaina[8] studied only anxiety and depression as patterns of psychosocial disorders. This may not give a general overview of the overall prevalence of psychosocial disorders. The high prevalence of psychosocial disorders reported in this study may be due to the high burden of providing care for HIV-infected children in a resource-poor setting. The lower prevalence observed by New et al.,[27] in Washington, and Santiesteban et al.,[7] in Cuba, can be attributed to the difference in their sample size and study population. The subjects in this study comprised 154 caregivers, whereas New et al.[27] and Santiesteban et al.[7] studied 54 and 13 caregivers, respectively. Thus, their sample size may not have provided a real representation of the caregivers. Also, the study population in this study comprised caregivers whose children were aged between 2 and 15 years, whereas New et al.[27] recruited caregivers of HIV-infected children aged between 6 and 12 years. These may be responsible for the differences in the prevalence.

In this study, 73.3% of the caregivers with psychosocial disorders were also HIV infected. This is comparable to the findings by Ji et al.[6] in China in 2007. This high prevalence was also documented by Santiesteban et al.[7] and Fawzi et al.[11] The daily burden of providing care to both the HIV-infected and uninfected family members by these caregivers, who were also infected, may be responsible for the observed high prevalence. Despite the high prevalence, this study did not find any significant relationship between the psychosocial disorders and the subjects who were HIV infected. This lack of a significant relationship was also observed by New et al.[27] This may be due to the fact that caring for an HIV-infected child poses great stress to the caregivers, irrespective of their HIV status.

This study showed that 60% of the caregivers of HIV-infected children with psychosocial disorders were aged 20–39 years. This contrasts with the study by Lv et al.,[14] in China, who observed that a higher proportion of the caregivers were aged above 40 years. This variation may be due to proper health-seeking behavior, increased awareness of primary prevention of diseases, and reduced poverty as seen in developed countries compared to that of resource-poor countries such as Nigeria. It could also be due to the variation in their sample size and tools for the assessment of psychosocial disorders. The high prevalence of 60% observed among the caregivers aged 20–39 years in our study may be due to the fact that this age group belongs to the sexually active group, a significant risk factor for HIV infection in resource-poor setting. Therefore, they may also be infected and have accompanied their children to the hospital so as to benefit from the HIV treatment and support programs. However, despite this high prevalence, this study did not find any significant relationship between psychosocial disorders and the age groups of the caregivers. This may be attributed to the fact that the high burden of caring for the HIV-infected child may have negative effects on the caregivers irrespective of their age differences.

In this study, 95% of the caregivers of the HIV-infected children with psychosocial disorders were females. This was comparable to 92.3% observed by Santiesteban et al.[7] in Cuba. Similar findings were observed by Wainaina[8] and Lv et al.[14] in Kenya and China, respectively. A statistically significant association was observed between female caregivers of HIV-infected children and psychosocial disorders. The high proportion of females observed in this study and other studies highlights the role women play in our society as the guardian of the family health.[13] Thus, females are more involved in the continuous provision of care and support for their family members. In the presence of battling with her own HIV diagnosis, the female caregiver is also providing care to her HIV-infected child and partner.

In this study, 61.7% of the caregivers whose HIV-infected children were aged less than 5 years had psychosocial disorders. A statistically significant association was observed between the age group of the HIV-infected children and psychosocial disorders. The study also showed that the caregivers whose HIV-infected children were aged 8–10 years were less likely to develop psychosocial disorders when compared to other age groups of the HIV-infected children. These observations may be attributable to the fact that the care of sick children aged less than 5 years has a higher burden compared to that of older children who would have achieved some level of independence. Thus, the children aged 8–10 years in this study, may have achieved some level of independence, resulting in reduced stress and burden on their caregivers. The findings of statistically significant association between psychosocial disorders and caregivers of HIV-infected children were also noted by Lv et al.[14] However, their study did not classify these children into various age groups and as such may not enable comparison.

In this study, 86.7% of the caregivers of the HIV-infected children belonged to the lower socioeconomic class, 35% were married, 48.3% had lost their spouse to death (widowed), 10% were divorced, 85% had an additional HIV-infected family member, whereas 53.3% lacked the support of their spouse. These findings were significantly associated with psychosocial disorders, except for a married caregiver. These high prevalence were also noted by Potterton et al.[12] in South Africa in 2007, Wainaina[8] in Kenya in 2012, Ji et al.[6] in China in 2007, Lv et al.[14] also in China in 2010, Fawzi et al.[11] in Haiti in 2010, and Santiesteban et al.[7] in Cuba in 2012. A married caregiver of an HIV-infected child is less likely to develop psychosocial disorders. This may be due to the continuous provision of support by either of the couple during stressful periods. The family is the caregiver’s main support and failure of this support may result in dissatisfaction or reduced level of functioning on the part of the caregivers. This may have contributed in the significant association between lack of spouse support, death of a spouse, presence of an additional HIV-infected family member, and the psychosocial disorder. Also, belonging to the lower socioeconomic class increases financial burden, which precipitates stressors that lead to psychosocial disorders. Despite this, Bachanas et al.[26] in Atlanta, did not find any significant relationship between socioeconomic status, family support, and psychosocial disorders. This variation may be due to their sample size and study population. Although 154 subjects and 154 controls were sampled in this study, Bachanas et al.[26] studied 36 subjects and 32 controls. In addition, the study population in this study included caregivers from the upper, middle, and lower social classes, whereas those of Bachanas et al.[26] (both subjects and controls) were based solely on individuals from the low socioeconomic class. These may have been responsible for the observed variance. It is noted that 6.7% of the caregivers in our study were single. However, no significant association is observed between psychosocial disorders and being a single caregiver of an HIV-infected child. This may be attributable to the fact that the single caregivers may have developed some coping strategies that enable them to withstand stressful events, unlike a married caregiver who may be dependent on the spouse during stressful situations.


  Conclusion Top


This study has shown that there is a high prevalence of psychosocial disorders among the caregivers of HIV-infected children. It also revealed that female gender, lower socioeconomic class, divorce, widowhood, unsupportive spouse, caring for under five children, and the existence of an additional HIV-infected family member determine the presence of psychosocial disorders in the caregivers of HIV-infected children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yogev R, Chadwick EG Acquired immunodeficiency syndrome (human immunodeficiency virus). In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016. pp. 1645-66.  Back to cited text no. 1
    
2.
Tindyebwa D, Kayita J, Musoke P, Eley B, Nduati R, Coovadia H, et al. editors. Handbook of Paediatric AIDS in Africa. 4th ed. Kampala, Uganda: Kluwer academic publishers; 2017. pp. 3-84.  Back to cited text no. 2
    
3.
Ogunbosi BO, Oladokun RE, Brown BJ, Osinusi KI Prevalence and clinical pattern of paediatric HIV infection at the University College Hospital, Ibadan, Nigeria: A prospective cross-sectional study. Ital J Pediatr 2011;37:29.  Back to cited text no. 3
    
4.
Kadke A, Bhagyalakshmi K, Jeena V A study of psychosocial problems in families with HIV-infected children in coastal Karnataka. GMBHS 2011;3:72-5.  Back to cited text no. 4
    
5.
Martin C, Nisa M Meeting the needs of children and families in chronic illness and disease. A greater role for the GP? Aust Fam Physician 1996;25:1273-5, 1277, 1279-81.  Back to cited text no. 5
    
6.
Ji G, Li L, Lin C, Sun S The impact of HIV/AIDS on families and children—A study in China. AIDS 2007;21:S157-61.  Back to cited text no. 6
    
7.
Santiesteban Y, Castro M, Calvo M Mental health of primary caregivers for children and adolescents with HIV/AIDS in Cuba. MEDICC Rev 2012;14:30-4.  Back to cited text no. 7
    
8.
Wainaina AM The prevalence of anxiety and depression among caregivers of HIV-positive children. 2012 (cited 2013 June 23). Available from: http://erepository.uonbi.ac.ke/handle/11295/6854. [Last accessed on 2018 Dec 05].  Back to cited text no. 8
    
9.
Petrushkin H, Boardman J, Ovuga E Psychiatric disorders in HIV-positive individuals in urban Uganda. Psychiatrist 2005;29:455-8.  Back to cited text no. 9
    
10.
Li L, Liang LJ, Ding YY, Ji G Facing HIV as a family: Predicting depressive symptoms with correlated responses. J Fam Psychol 2011;25:202-9.  Back to cited text no. 10
    
11.
Fawzi SMC, Eutache E, Oswald C, Surkan P, Louis E, Scanlan F et al. Psychosocial functioning among HIV-affected youth and their caregivers in Haiti: Implication for family focused service provision in high HIV burden settings. AIDS Patient Care STD 2010;24:147-58.  Back to cited text no. 11
    
12.
Potterton J, Stewart A, Cooper P Parenting stress of caregivers of young children who are HIV positive. Afr J Psychiatry (Johannesbg) 2007;10:210-4.  Back to cited text no. 12
    
13.
Chandra PS, Desai G, Ranjan S HIV and psychiatric disorders. Indian J Med Res 2005;121:451-67.  Back to cited text no. 13
    
14.
Lv Y, Zhao Q, Li X, Stanton B, Fang X, Lin X, et al. Depression symptoms among caregivers of children in HIV-affected families in rural China. AIDS Care 2010;22:669-76.  Back to cited text no. 14
    
15.
Grover G, Pensi T, Banerjee T Behavioural disorders in 6-11-year-old, HIV-infected Indian children. Ann Trop Paediatr 2007;27:215-24.  Back to cited text no. 15
    
16.
Kabbash IA, El-Gueneidy M, Sharaf AY Burden, strain and coping strategies among caregivers of persons living with HIV. Bull Alex Fac Med 2007;43:515-6.  Back to cited text no. 16
    
17.
Whitley E, Ball J Statistics review 4: Sample size calculations. Crit Care 2002;6:335-41.  Back to cited text no. 17
    
18.
Oyedeji GA Socioeconomic and cultural health background of hospitalized children in Ilesa. Nig J Paediatr 1985;12: 111-7.  Back to cited text no. 18
    
19.
Eziyi JAE, Amusa YB, Nwawolo CC, Ezeanolue BC Wax impaction in Nigerian school children. East Cent Afr J Surg 2011;16:40-5.  Back to cited text no. 19
    
20.
Okoromah CA, Ekure EN, Lesi FE, Okunowo WO, Tijani BO, Okeiyi JC Prevalence, profile and predictors of malnutrition in children with congenital heart defects: a case-control observational study. Arch Dis Child 2011;96:354-60.  Back to cited text no. 20
    
21.
Jarrett OO, Fatunde OJ, Osinusi K, Lagunju IA Pre-hospital management of febrile seizures in children seen at the university college hospital, Ibadan, Nigeria. Ann Ib Postgrad Med 2012;10:6-10.  Back to cited text no. 21
    
22.
Goldberg D. Identifying psychiatric illness among general medical patients. BMJ 1985;291:161-2.  Back to cited text no. 22
    
23.
Udofia O, Oseikhuemen AE Psychiatric morbidity in patients with sickle cell anaemia. West Afr J Med 1996;15:196-200.  Back to cited text no. 23
    
24.
Morakinyo O The sensitivity and validity of cornell medical index and the General Health Questionnaires in an African population. Afr J Psychiatr 1979;2:1-8.  Back to cited text no. 24
    
25.
Odejide AO, Ladipo OA, Otolorin EO, Makanyinola JDA Infertility among Nigerian women: A study of related psychological factors. J Obst Gyn East Cent Afr 1980;5:61-3.  Back to cited text no. 25
    
26.
Bachanas PJ, Kullgren KA, Schwartz KS, McDaniel JS, Smith J, Nesheim S Psychological adjustment in caregivers of school-age children infected with HIV: Stress, coping, and family factors. J Pediatr Psychol 2001;26:331-42.  Back to cited text no. 26
    
27.
New MJ, Lee SS, Elliott BM Psychological adjustment in children and families living with HIV. J Pediatr Psychol 2007;32:123-31.  Back to cited text no. 27
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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