It's harder for boys? Children's representations of their HIV/AIDS-affected peers in Zimbabwe.

This study examines whether children in rural Zimbabwe have differing representations of their HIV/AIDS-affected peers based on the gender of those peers. A group of 128 children (58 boys, 70 girls) aged 10-14 participated in a draw-and-write exercise, in which they were asked to tell the story of either an HIV/AIDS-affected girl child, or an HIV/AIDS-affected boy child. Stories were inductively thematically coded, and then a post hoc statistical analysis was conducted to see if there were differences in the themes that emerged in stories about girls versus stories about boys. The results showed that boys were more often depicted as materially deprived, without adult and teacher support, and heavily burdened with household duties. Further research is needed to determine whether the perceptions of the children in this study point to a series of overlooked challenges facing HIV/AIDS-affected boys, or to a culture of gender inequality facing HIV/AIDS-affected girls - which pays more attention to male suffering than to female suffering.

Introduction

The AIDS epidemic in sub-Saharan Africa has had significant impacts on the lives of children as they increasingly take on caring for sick parents or relatives, and other household duties (Becker, 2007; Skovdal, Ogutu, Aoro, & Campbell, 2009). However, these impacts have had varying effects on the lives of boy and girl children. Many studies have emphasized the negative effects of HIV/AIDS on girls' school attendance (Alabi, Bahah, & Alabi, 2013; Andrews, Skinner, & Zuma, 2006; Guo, Li, & Sherr, 2012; Kobiané, Calvès, & Marcoux, 2005; Robson, Ansell, Huber, Gould, & van Blerk, 2006). In addition, a growing body of research has concentrated on the effects on children's household duties, demonstrating that girls often take on a heavier burden of nursing and household work when caring for other household members (Alabi et al., 2013; Francis-Chizororo, 2010; Robson et al., 2006). This reflects typical gendered divisions of labour, in which girls cook, care for others and perform domestic work, while boys are involved in public income-generating activities outside the house, such as farming and trade (Francis-Chizororo, 2010; Skovdal et al., 2009). New studies, however, have shown that the gendered division of household labour is perhaps becoming less salient in the face of severely limited material resources, particularly demonstrated by boys' increasing participation in care work (Francis-Chizororo, 2010; Kesby, Gwanzura-Ottemoller, & Chizororo, 2006; Robson et al., 2006; Skovdal et al., 2009).

This paper presents further perspective on the different impacts of HIV/AIDS on boys and girls through a secondary analysis of data from a draw-and-write exercise, conducted with 128 children in rural Zimbabwe as part of a broader multi-method study (Campbell et al., 2014). The original study sought to understand how children affected by HIV/AIDS are supported through their schools. The current paper looks at how children's perceptions of their HIV/AIDS-affected peers differ based on the gender of those peers, and focuses particularly on children's work within households.

As Campbell et al. (2014) note, it is important to understand children's perceptions of their HIV/AIDS-affected peers as it gives insight into how public health specialists can better support and respond to their needs in difficult situations. This can be particularly useful when attempting to understand and confront stigma among children. In their work on child-on-child stigma, Campbell, Skovdal, Mupambireyi, & Gregson (2010) find that negative representations of HIV/AIDS-affected children (as tragic, rejected, over-burdened) are simultaneously accompanied by more positive representations as well (as deserving of respect and compassion). Skovdal et al. (2009) also demonstrate the complex social identities of young carers by highlighting their resilience and coping abilities. Children's perceptions of their peers, themselves and their different responsibilities are dynamic and multifaceted.

Few studies to date have looked at children's representations of their HIV/AIDS-affected peers by gender. This paper seeks to understand how children's representations of HIV/AIDS-affected boy children differ from their representations of HIV/AIDS-affected girl children. The findings suggest that children perceive HIV/AIDS-affected boys to be more materially deprived, less able to leverage adult and teacher support and more heavily burdened with household work than HIV/AIDS-affected girls. We suggest that although boys are represented as having a harder time coping than girls, these perceptions might be complicated by traditional gender norms about who performs different household tasks, and may not necessarily be indicative of higher workloads for boys.

Methods

The data used for this paper were collected in a rural school in the Manicaland province of Eastern Zimbabwe, in July 2012. They were collected as part of a broader multi-method study that sought to understand how schools support HIV/AIDS-affected children (Campbell et al., 2014). To honour confidentiality guarantees made to participants, the precise study district and village cannot be named; however, their description is as follows.

The study school is located in a village centre, situated within a large rural district containing widely dispersed small communities, churches and a mission hospital. In the rural area surrounding the village, families live in isolated or clustered homesteads, and engage in subsistence farming. They grow vegetables and breed livestock, both for their own use, and for sale. At the village centre is a small clinic, a small local church and a few wooden kiosks selling basic supplies and milk. Children walk to school, sometimes over long distances, for several hours.

Adults in the area often belong to local groups, such as church groups, women's groups and savings clubs. Some act as community health workers. Many children rely on the Basic Education Assistance Module (BEAM), a social protection programme, spearheaded by the government of Zimbabwe and supported by foreign donors. It helps children with textbooks, uniforms and school fees. There has been sporadic NGO activity to support HIV/AIDS-affected people in the area, and there is a local community-based organisation that supports orphaned and vulnerable children with food- and school-related expenses; however, such support is inconsistent due to lack of funding. This is the context in which the study school is situated.

With the school's consent, children were invited to stay after classes one afternoon and participate in a writing and drawing exercise. All of the children at school that day attended, yielding a total of 128 participants (58 boys, 70 girls), aged 10–14.

The students were given 90 minutes to write a story and draw a picture about a student who was affected by HIV/AIDS, with half of the students randomly allocated to write about a boy and half of the students randomly allocated to write about a girl. The directions were as follows:

How does HIV affect children at your school? Write a story of a child who is affected by HIV (HIV infected/sick relatives/orphaned). What challenges does this child face? How does the school help this child to overcome difficulties in his or her everyday life? Draw a picture to accompany your story.

The draw-and-write approach was chosen in order to given children a variety of ways to express themselves. However, in the end the written stories were clearer and more complete than the drawings, and were therefore the focus of analysis. As mentioned above, this study involved a secondary analysis of the data produced by the children to explore possible gender differences in children's representations of their HIV/AIDS-affected peers. The stories were inductively coded for the original analysis (Campbell et al., 2014) using thematic content analysis (Attride-Stirling, 2001). The coding frame had 53 basic themes, which were grouped into 19 organising themes and 6 global themes. These can be seen in Table 1.

Table 1.

Coding frame.

Global themes	Organising themes	Basic themes
Character narratives of HIV/AIDS-affected children	Children as victims	Express sympathy and pity for child
	Positive representations of child	(Intelligent, likeable, beautiful, responsible, hard-working, obedient, good in school, morally good)
	Children as morally problematic	Child associated with ‘Bad behaviour’ (promiscuous, alcohol, foolish)
Representations of the life situation of HIV/AIDS-affected children	Representations of HIV/AIDS-affected households	Household looks visibly poor (dirty, dying flowers, lack of basic essentials, dying animals) Positive physical appearance of household (beautiful, clean, livestock)
	Representations of the parents of HIV/AIDS-affected children	AIDS visible through behaviour & condition of parents (sleeping, unable to work, hospital visits, look sick) Limited supportive adults in household (evident in lack of social, emotional or economic support)
	Representations of social circumstances in the homes of HIV/AIDS-affected children	Children neglected/abused/seen as burdens in their households Children receiving social support in their households
	Duties of HIV/AIDS-affected children	Child engaged in caregiving activities (intimate nursing, bathing, administrating medicine, feeding) Child engaged in household duties Child's duties as exploitation by relatives Duties carried out by a child lacking food Duties carried out by sick child Duties compromise safety and well-being of the child Duties hinder child from social engagement (playing) Child engaged in income-generating activities
	Community responses to HIV/AIDS-affected children	Extended family support Community supports HIV/AIDS-affected child Community responds negatively to HIV/AIDS-affected child
How challenges of HIV/AIDS-affected children manifest within the school environment	Impact on school attendance	School drop out Late for school
	Material deprivation	Lack of school equipment (uniform, pens, books, fees) Lack of food (comes to school without eating) Child looks visibly poor (poor clothing, dirty, rags, torn clothes)
	Physical health	Child shows symptoms of poor physical health (pain, tiredness, fainting, sleeping, vomiting) Child looks visibly sick (cracked lips, skinny) Child visits hospital/health clinics
	Emotional health	Child shows symptoms of poor emotional health (sad, crying, fear, worry about home situation, miserable, stressed)
School as a negative context for HIV/AIDS-affected children	Teachers' negative responses to HIV/AIDS-affected children	Teacher sends child away from school Teacher abuses child
	Social exclusion	Child experience social exclusion (isolation, lack of friends) Child experience bullying Child stigmatized
School as a source of positive support	Teachers (including school and head master) support beyond education	Teachers as guardians (emotional/counselling/advice/comfort) Teachers provide material support (pens, books, fees, uniform/clothes, soap) Teacher assists with food/water Teacher encourages inclusion of HIV/AIDS-affected children Other – not specified School aware of home situation of child
	Peer support	Peers share materials (pens, books) Peers share food Peer interaction and emotional support Peers help with chores
	Bridges between schools and outside sources of support	School spaces as platform for referral to health clinics NGOs BEAM Chiedza
	Routes to positive social identities	Schools as distraction from life tragedies (happy, forget home situation) Positive perceptions of children's school performance
Extra coding	Perceptions of HIV/AIDS	Contagion of HIV ART HIV perceived as ‘killer disease’

For the secondary analysis, to see if there were differences in the ways that girl children and boy children were represented in the stories, a post hoc statistical analysis was conducted. It looked at the association between each organising theme, and the gender of the child described, using chi-squared tests. (The level of organising theme was chosen for significance testing because at the level of global theme, specificity is lost, and at the level of basic theme, expected counts were often less than five.) Nineteen chi-squared tests were run, in which the independent variable was the sex of the child described, and the dependent variable was the presence (or absence) of one of the organising themes. Four of the tests yielded statistically significant results, and these are reported in Table 2. (A further nineteen chi-squared tests were run in which the independent variable was the sex of the child writing the story; however, these yielded no statistically significant results.)

Table 2.

Differences in prevalence of organising theme according to sex of child described.

Organising themes	Male describedN=62	Female describedN=66	Chi-squared value	Degrees of freedom	p-Value (Chi-squared test)
Material deprivation
Lack of school equipment (uniform, pens, books, fees) Lack of food (comes to school without eating) Child looks visibly poor (poor clothing, dirty, rags, torn clothes)	39%	23%	3.855	1	.050a
Representations of the parents of HIV/AIDS-affected children
AIDS visible through behaviour & condition of parents (sleeping, unable to work, hospital visits, look sick) Limited supportive adults in household (evident in lack of social, emotional or economic support)	87%	70%	5.663	1	.017a
Teacher (including school and head master) support beyond education
Teachers as guardians (emotional/counselling/advice/comfort) Teachers provide material support (pens, books, fees, uniform/clothes, soap) Teacher assists with food/water Teacher encourages inclusion of HIV/AIDS-affected children Other – not specified School aware of home situation of child	21%	42%	6.760	1	.009a
Duties of HIV/AIDS-affected children
Child engaged in caregiving activities (intimate nursing, bathing, administrating medicine, feeding) Child engaged in household duties Child's duties as exploitation by relatives Duties carried out by a child lacking food Duties carried out by sick child Duties compromise safety and well-being of the child Duties hinder child from social engagement (playing) Child engaged in income-generating activities	53%	17%	18.941	1	<.000b

aSignificant at the 5% significance level pre-Bonferonni correction (critical p-value .05).

bSignificant at the 5% significance level post-Bonferonni correction (critical p-value .001).

Once the test statistics and corresponding p-values were obtained, the Bonferroni correction was applied to counteract the problem of multiple comparisons (Field, 2013); because the desired significance level was 5%, the original critical p-value (0.05) was divided by the total number of comparisons being made (38) to yield a new critical p-value (0.001) required for significance at the 5% significance level. The results are presented in Table 2.

For those organising themes where statistically significant differences were observed, the data were revisited to draw out the qualitative nuances. In revisiting the data, close attention was paid to the basic themes that comprised the organising themes, in order to interpret the meaning of the quantitative differences in organising themes, and to add qualitative insights.

Results

Children's representations of HIV/AIDS-affected boys differ from their representations of HIV/AIDS-affected girls along four dimensions: material deprivation, adult support at home, teacher support at school and household duties. Statistically significant differences in the four organising themes associated with these dimensions are presented in Table 2.

Only one of these organising themes – duties of HIV/AIDS-affected children – showed statistically significant differences at the 5% significance level once the new critical p-value (0.001), derived from the Bonferroni correction, was applied. However, because the Bonferroni correction can be somewhat conservative (Field, 2013), all four themes were revisited to draw out qualitative nuances.

Material deprivation

The issue of material deprivation emerges more in stories of boy children than in stories of girl children. (It comes up in 39% of stories depicting boy children compared with only 23% of stories depicting girl children.) Specifically, boy children are more frequently depicted as lacking necessities such as food, clothing, pens, books, school uniforms and school fees:

There is a boy whose parents died of AIDS … He doesn't have food. He is always hungry. He doesn't have anyone to pay school fees for him and he doesn't have clothes. He wears rags.

The boy does not have school fees or anyone to buy him shoes or [a] school uniform.

Limited adult support at home

Boys were also more frequently described as having limited adult support at home. They were shown to have sick parents, or to lack supportive adults in the household – as evidenced by a lack of social, emotional and economic support. (This comes up in 87% of stories depicting boys compared with only 70% of stories depicting girls.) The data show that boy children with limited adult support can be loosely grouped into three categories. Firstly, there are those who have limited adult support because one or both of their parents are sick:

There is a boy … who lives with parents who are ill … He wakes up in the morning to fetch water, cook for them, bath them and give them pills. He does not carry food to school. Others are always laughing at him at school because his parents are ill … He is always crying but he is a hard worker. When he is on holiday he tries to take care of his parents and buys pills for them. He likes his parents. When he comes back from school he ploughs and waters the field.

Secondly, there are those who have limited adult support because their parents are dead, and they have been sent to live with unsupportive relatives:

In our village there is a boy whose parents passed away. This boy is always abused by the people he stays with … He is sad because his guardians abuse him. They don't give him food and he doesn't have a school uniform.

This boy had his mother and father who were HIV positive. The mother was the first to die of the disease then the father was next. The boy was the only child in this family and he was taken care of by his close relatives. The boy started being abused by the relatives who had said they wanted to take care of him.

Finally, there are those who have limited adult support because they live in child headed households:

I want to talk about a boy that l know. I know this boy because he has no parents. He stays alone at his home. It troubles me that no one sees to it that the boy gets food because he has a deadly disease. His mother died of HIV.

He does everything, washing dishes, fetching water, washing clothes and ironing them. His mother and father died so he is the only one who is in the family together with five orphans.

The same three scenarios emerge for girl children; however, the general theme (limited adult support at home) emerges less frequently for girls than for boys.

Less teacher support at school

Not only are boy children depicted as having less adult support at home compared with girl children, they are also depicted as having less teacher support at school compared with girl children. (Support from teachers is mentioned in 42% of stories depicting girls compared with only 21% of stories depicting boys.) The support offered to girl children can take various forms. Most often it takes the form of material assistance with things such as books, pens, food, uniforms and school fees:

Her parents died of AIDS last year. The school pays for her school fees, buys her clothes, uniforms, shoes, books, pens, pencils and other things.

At school, teachers help her with uniform, food and clothes.

It can also include emotional support, such as counselling, comfort, inclusion and advice:

I write this composition to tell you about a girl who is sick with HIV … She goes to school and she is in grade five … .The teachers and her friends give her some advice …

The girl that l know who is HIV positive … This girl is never happy in his life. When she is at school the teachers try to help her in various ways. The teachers ask the girl what she wishes the school to do for her …

Boys are also sometimes shown receiving material and emotional support from teachers:

His school helps him by giving him books and pens.

Sometimes teachers take him when he is crying.

However, such support comes up less often in stories about boys. Moreover, there are forms of support that only appear in stories about girls. Specifically, girls are depicted receiving: accommodation, medication, money, soap, lotion, transportation to school and assistance procuring a national ID card. Boys are not. This is depicted in Figure 1.

Figure 1.

Type of support received from teacher and/or school, by gender.

Heavy burden of household duties

Finally, boys are more frequently depicted carrying a heavy burden of household duties. (Duties come up in 53% of stories depicting boys compared with only 17% of stories depicting girls.) The duties that boys have to perform include those that are traditionally male, and those that are traditionally female. As discussed above, traditionally male duties include farm work such as ploughing, cutting firewood and taking care of livestock (Francis-Chizororo, 2010; Skovdal et al. 2009):

He is always crying but he is a hard worker … When he comes back from school he ploughs and waters the field.

This boy works for himself and cuts firewood at his house.

When he got home he would do all the household chores and go to herd cattle. When he got home he would find that no food had been prepared and this always troubled this young boy.

I know of a boy who has problems and is also an orphan … When [he] gets back from school he looks after goats. The boy is twelve years old and both his parents passed away.

However, boys were also frequently depicted performing traditionally female duties such as fetching water, cooking, washing dishes and clothes, bathing others and caring for people (Francis-Chizororo, 2010; Skovdal et al., 2009):

There is a boy … who lives with parents who are ill … He wakes up in the morning to fetch water, cook for them, bath them and give them pills.

The boy I know is always sick … This boy is very hard working. He does household chores when he comes back from school. He fetches water and washes dishes. This boy bathes males who are ill who stay at his home. Before going to school he does household chores and bathes the sick people.

This boy takes care of sick people at his home … When he returns from school he is the one who cleans the house.

The boy is always unhappy because he is always sent on errands. He does not go to school because he has to cook and provide care for orphans the whole day. He does everything, washing dishes, fetching water, washing clothes and ironing them.

Considerable sympathy is expressed for boys who have to work. For example, in the performance of their duties, boy children are often portrayed as exploited by their relatives:

I know of a boy who is sick with AIDS … His grandfather is always making him do heavy chores.

Today I want to speak about a boy who is abused … He stays with his grandmother but the grandmother tells him to go and fetch water for her. His mother died of sugar diabetes.

There is a boy who used to stay in our village. He was always abused. This boy cries everyday because of the abuse. He fetches water before going to school. You would see him everyday fetching water in the cold without wearing enough clothes.

It is also noted that boys must carry out duties when they are hungry or sick:

A boy has parents who have HIV. This boy is also HIV positive. He is sent to fetch firewood and cook sadza but this boy is also sick.

This boy is almost always sick because he is dirty. This boy ploughs the fields.

Similar sympathy is expressed for girl children who have to work. However, as previously noted, far less reference is made to the work of girl children than to the work of boy children. Another observable difference is that when girl children are depicted carrying a heavy burden of household duties, they are usually depicted performing traditionally female duties, while boys are depicted performing both male and female duties. We discuss this further below.

Discussion

The results of this analysis show that, among children, there seems to be a perception that HIV/AIDS-affected boys are more materially deprived, less supported by adults and teachers and more burdened with household duties than HIV/AIDS-affected girls. Girls, on the other hand, are seen as the recipients of more teacher and adult support, and their household work is less noted. This could be because girls are accustomed to performing household duties, and are able to leverage social norms of female dependence to garner support from adults.

On the other hand, in a context where men have more power than women, it may be that male suffering is more notable than female suffering. Other studies have suggested that HIV/AIDS disproportionally disadvantages girls – for example, with respect to school enrolment (Alabi et al., 2013; Andrews et al., 2006; Kobiané et al., 2005; Robson et al., 2006). When it comes to household duties, boys performing duties traditionally reserved for girls may simply attract notice because it goes against established gender norms. It may not actually be indicative of an overall higher workload for boys.

Moreover, while the depiction of boys performing female duties may herald a disruption of gender norms, gender norms may equally be reinforced. Boys may be garnering more attention and sympathy than girls when they have a heavy domestic workload.

Conclusion

The results of this study point to the need for further research into whether HIV/AIDS-affected boys do indeed experience more material deprivation, less adult and teacher support and a heavier burden of household duties than HIV/AIDS-affected girls. Children's own perceptions in rural Zimbabwe suggest this to be the case. If there is merit in this view, then the current study might be pointing to an important and overlooked aspect of the effects of HIV/AIDS on children – namely that it is more difficult for HIV/AIDS-affected boys to leverage support from adults and teachers, and that a heavy burden of household responsibilities falls on their shoulders. Organisations working to support HIV/AIDS-affected children may benefit from understanding these unique challenges facing boys.

If, on the other hand, the perceptions of the children in this study are not based on real differences – that is, if the challenges facing HIV affected boys and girls are broadly similar – then the study points to a different set of implications. The suffering of boy children may simply be more noticeable than the suffering of girl children, leading to greater sympathy for HIV/AIDS-affected boys, and less peer support for girls. This too would be important information for organisations working to support HIV/AIDS-affected children. Girls may need their suffering to be acknowledged and recognized by their peers, in order to leverage the sympathy and social support available to their male counterparts.