Scholastic performance and ambitions in retropositive and vulnerable pediatric patients: A prospective study.

Introduction: It is widely recognized that HIV epidemic has a negative impact on retropositive pediatric patients. However, at present, the school performance and ambitions in retropositive and vulnerable pediatric patients from India are lacking. Aims: The aim of this study was to analyze the possible association between scholastic performance and ambitions in retropositive and vulnerable status in pediatric patients. Materials and
Methods: Case-control study was conducted over a period of 2 years. Forty-two retropositive, vulnerable, and equal age- and gender-matched controls between the age of 6 and 16 years were included. All children or parents were enquired about performance, attendance, grades in last academic year, and their ambitions in life. The data were collected in a prevalidated questionnaire and analyzed using SPSS Version 20.
Results: A total 42 children between the age of 6 and 16 years were included. Twenty-seven (64.3%) were males and 15 (35.7%) females. Eleven (26.2%) were retropositive, 27 (64.3%) had one infected parent, and 4 (9.5%) patients had both the parents retropositive. Twelve (28.5%) cases failed their previous academic years compared to 1 (2.3%) control. Only 2 (4.7%) had attendance more than 90% in cases as compared to 18 (42.8%) among controls. Twenty-one (50%) attributed feeling of isolation as a cause of poor academic performance, while none of the controls did the same. There was a significant association between poor grades and poor attendance at school and retropositive (P < 0.001). The odds ratio of feeling of isolation was 1.62.
Conclusion: Retropositive and vulnerable status significantly affect the academic performance and ambitions in these children. Copyright:

The number of children orphaned due to HIV continues to rise all over the world with its epicenter in sub-Saharan Africa, which continues to be hardest hit. The most recent data from the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that the number of children orphaned to HIV has risen dramatically from 10 million in the year 2001 to 16.6 million in 2009.[1]

In India, pediatric age group accounts for 12% of all new HIV infections and an estimated 145,000 children below the age of 15 years are infected with HIV. It is estimated that approximately 10,000 new infections are added every year to the existing pool of HIV-infected children.[23] Although the existing literature has proved beyond all the doubts that children with HIV have educational disadvantage over their normal peers in terms of enrollment, attendance, behavior, and educational attainment, the impact of parental HIV on the educational outcomes in these children remains largely unknown.

While being orphaned by HIV have a direct effect in determining the education in these children, living with parents who are HIV positive can also drastically affect the adjustment, care, and educational outcome in children. Education of children affected as a result of HIV or made vulnerable as a result of parental HIV deserves a greater attention worldwide.[4] As a global phenomenon, AIDS-related stigma and discrimination are being reported in families, communities, religious organizations, educational institutes, and at workplace. This hampers the physical, mental, and scholastic performance in these children. These children are either avoided or shown excessive kindness and at times are forced to hide the illness.[56] Loss of either or both parents to HIV or assuming caregiver role to the family at a young age further complicates the situation for these children. In this study, we attempt to examine a possible link between various personal and contextual factors which has a potential to mediate the effect of HIV/AIDS in attaining various educational outcomes in children and compare it with normal age-matched controls. Review of literature reveals that most of the studies done so far highlight the school attendance as the only indicator of scholastic performance. This study was undertaken based on our outpatient department (OPD) experience and its relevance and to bridge the existing gap in the knowledge on this subject.

MATERIALS AND METHODS

It was a case–control study conducted over a period of 2 years from June 2018 to May 2020 in a tertiary care hospital where 42 consecutive retropositive patients between the ages of 6–16 years were included. Inclusion criteria were where either the child has HIV or has a vulnerable status by virtue of one or both parents being HIV positive. Equal number of age- and gender-matched HIV-negative children (both the parents are also HIV-negative) who accompanied their parents, sibling, or friends was recruited from hospital OPD as controls. All the children/parents were interviewed in the presence of a child counselor. Permission of the institutional ethics committee was obtained, and written informed consent was taken from the children or the guardian wherever applicable. For practical purposes, the attendance, result, grades, and attendance of last one academic year were included. Children/parents were enquired about their ambitions with regard to education and the reason of poor academic performance. We did not attempt to study confounding factors such as other physical or mental illnesses in children or their parents, occupation of the parents, relationship with caregivers, gender of the head of the family, external assistance to the family, socioeconomic status of the family, or their birth order. Data were collected using a prevalidated closed-ended questionnaire and analyzed using Statistical Package for the Social Sciences 20.0 (IBM Corp., IBM SPSS Statistics for Windows, Armonk, NY: USA).

RESULTS

A total of 42 children between the age of 6 and 16 years were studied out of which 27 (64.3%) were males and 15 (35.7%) females. Equal number of age- and gender-matched healthy controls were recruited from dermatology OPD. Eleven (26.2%) children were HIV positive, 27 (64.3%) children had one parent suffering from HIV as compared to 4 (9.5%) children with both the parents infected with HIV. Sixteen (38%) children were in the age between 10 and 12 years, 10 (23.8%) between 13 and 15 years, and 8 (19%) each in 6–9 years and 15–16 years.

Among cases, eight (19%) children were not formally enrolled in school, three (7.1%) were in preschool, 15 (35%) children were in primary, eight (19%) in middle, four (9.5%) in high school, and four (9.5%) children were in higher secondary classes. The distribution of the level of classes among controls is given in Table 1.

Table 1

Sociodemographic profile of cases and controls

Sociodemographic parameter	Frequency (%)
	Cases	Controls
Gender
Female	15 (35.7)	15 (35.7)
Male	27 (64.3)	27 (64.3)
HIV + children
No	31 (73.8)	0
Yes	11 (26.2)	0
1 parent HIV+
No	15 (35.7)	0
Yes	27 (64.3)	0
Both parents’ HIV+
No	38 (90.5)	0
Yes	4 (9.5)	0
Age group (years)
6-9	8 (19)	8 (19)
10-12	16 (38)	16 (38)
13-15	10 (23.8)	10 (23.8)
15-16	8 (19)	8 (19)
Level of education
Not enrolled	8 (19.0)	0
Preschool	3 (7.1)	0
1st-5th standard	15 (35.71)	15 (35.71)
6th-12th standard	16 (38.09)	27 (64.23)

The scholastic performance and ambitions have been tabulated in Tables 2 and 3. The causative factors for poor academic performance have been tabulated in Table 4. Twelve (28.5%) cases had “failure” grades as compared to only one (2.3%) child in the control group. Only 2 (4.8%) cases had attendance of more than 90% as compared to 18 (42.8%) in the control group. Forty (95.2%) cases did not wish to pursue higher education as compared to only 8 (19%) children in the control group. Fifteen (35.7%) cases attributed chronic absenteeism as a cause of poor academic performance as compared to only two (4.7%) controls. Twenty-six (61.9%) cases reported the feeling of isolation, whereas none of the children in the control group reported the same.

Table 2

Comparison between cases and controls with respect to various outcome parameters (grades and attendance)

Parameter	Cases (%)	Controls (%)	P
Grades achieved at school
Grade A	3 (7.1)	18 (42.8)	0.000
Grade B	9 (21.4)	16 (38)
Grade C	7 (16.6)	7 (16.6)
Failed	12 (28.5)	1 (2.3)
Not enrolled	8 (19)	0
Preschool	3 (7.1)	0
Attendance at academic institution
<25%	11 (26.1)	4 (9.5)	0.000
50%-25%	10 (23.8)	5 (11.9)
50%-75%	9 (21.4)	6 (14.2)
75%-90%	2 (4.7)	9 (21.4)
>90%	2 (4.7)	18 (42.8)
Not enrolled	8 (19)	0

Table 3

Comparison between cases and controls with respect to various outcome parameters (ambitions in life and cause of chronic absenteeism)

	Cases (%)	Controls (%)	P
Desire to pursue higher education
No	40 (95.2)	8 (19)	0.00
Yes	2 (4.7)	34 (80.9)
Interest in education
Yes	33 (78.5)	41 (97.6)	0.015
No	9 (21.4)	1 (2.3)
To finish school
Yes	27 (64.2)	39 (92.8)	0.024
No	15 (35.7)	3 (7.1)

Table 4

Causes of poor academic performances among cases and controls

Parameter studied	Cases	Controls	P value
Chronic absenteeism (%)
No	27 (64.2)	40 (95.2)	0.001
Yes	15 (35.7)	2 (4.7)
Feeling of being ill constantly (%)
No	25 (59.5)	39 (92.8)	0.001
Yes	17 (40.4)	3 (7.1)
Feeling of isolation (%)
No	21 (50)	42 (100)	0.000
Yes	21 (50)	0
Loss of self-esteem (%)
No	16 (38)	42 (100)	0.000
Yes	26 (61.9)	0
Poor academic performance (%)
No	23 (54.7)	39 (92.8)	0.000
Yes	19 (45.2)	3 (7.1)

There was a significant association between poor grades and poor attendance at school and retropositive/vulnerable status (P = 0.000) [Tables 1 and 2]. The odds ratio of willingness to finish school/college was 1.3 times more in controls than cases. The odds ratio of feeling of isolation at school/college was 1.62 times more in cases than in controls. There was a significant association between feeling of isolation with disease and vulnerable status and lower grades (P = 0.0001) [Table 4]. The odds ratio of finishing primary school was 0.55 times in cases than in controls.

DISCUSSION

The rise in number of HIV/AIDS-infected children and children made vulnerable as a result of one or both parents being HIV positive is alarming. Children are often ignored as traditionally HIV is associated with sexual behavior and intravenous drug abuse. These children can manifest with either externalizing behaviors such as conduct disorders or as internalizing behaviors manifesting as anxiety or depression. They have to cope with the burden of illness, losing a family member to illness, social exclusion, financial constraints, providing the role of caregiver in some families, and complicated relation with the head of the family which add to their psychological distress and result in negative educational outcomes.[789] Although in recent few years, there is a steady decline in the new HIV infection among children largely as a result of improvement in accessibility of services preventing the transmission of virus from mother to child during pregnancy, labor, delivery, and breastfeeding, still at least 1000 babies are infected through transmission from mother world-over each day.[1011]

Studies have shown that education is affected differentially when there is maternal and paternal loss. Children are more likely and severely affected in cases of maternal loss which is seen as dropout from the school, poor attendance, delayed schooling, enrollments, and poor grades at school. On the other hand, paternal loss also eventually results in deteriorating socioeconomic status which can also result in school dropout, poor attendance, and poor grades. It can be postulated based on these studies that loss of mother is a strong indicator of poor educational factors outcome. HIV orphaned kids have more psychological and physical problems such as feeling of guilt, isolation, depression, anxiety, grief, and a low self-esteem which is twice more common in the case of loss of mother than father. The postulated reason for this gender difference is that a child is most likely to have more day-to-day contact with mother than father or other caregivers. Furthermore, mother is more likely to make adjustments to impart education to the kids as compare to father/caregivers.

Children with poor households are less likely to be enrolled in school and complete their education due to lack of food, school fee, and being engaged in domestic labor to meet the need of the household. Economic status of a family has a more important role than the orphanhood status in explaining the gap in school enrollment in these children.[1213] Role of family-centered service can be highlighted as these children if not supervised suffers from increased risk of abuse and exploitation which negatively affects their schooling and performance as they have less interest in schools, lower self-esteem, and less perceived social support as compared to retronegative and children with non-HIV parents.[14151617181920]

In the present study, we found that retropositive and vulnerable children had poor academic grades as compared to controls which is consistent with a study done by Constantino et al. where 90% of study participants reported poor academic performance which measures scholastic performance in children-headed families.[21] Similarly, the stigma and chronic absenteeism has been associated with retropositive status or being from a family where parents are HIV + ve in other studies also which is again in alignment with the findings in the present study.[21] The present study had 8 (19%) cases who were not enrolled in school formally. Li et al. found that approximately 7% of school-age AIDS orphans children did not go to school.[2223] In the present study, 17 (40.6%) students reported frequent illness in self or family as a cause of poor performance in school which is consistent with the findings of Eaton et al. where frequent health issue was found to be responsible for poor attendance at school/college.[24] However, due to lack of literature available on this topic, we could not find any study to compare our results. However, there are few limitations of our study like we did not take into account confounding factors such as physical or mental disability, financial status, relation between children and caregiver, gender of caregiver, their socioeconomic factors, type of family or birth order, and any external assistance to the family. Furthermore, we studied a limited number of children and had a lack of similar data in the Indian scenario to compare our study. We propose that another study on a large population taking into account these confounding factors under similar study setting would be highly informative to bridge the existing gap in the knowledge.

CONCLUSION

Education of HIV-affected and vulnerable children deserves a greater attention worldwide. Schooling and education are universally accepted to be crucial for child development and its far-reaching impact on society and country at large. In light of this UN Convention in 1989 advocated the right to education for children in article 28 of the rights of the children (UNICEF) which says children have the right to education. Discipline in schools should respect children's human dignity. Primary education should be free and wealthier countries should help poorer countries to achieve this.[25] However, educational rights remain still at stake for millions of children, more so for these unfortunate children. Schools need to provide an optimistic outlook for life in these children to break the psychological guilt-poverty cycle.[26]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.