Introduction

Sub-Saharan Africa (SSA) is experiencing a high number of orphans due to the prevalence of HIV/AIDS [1]. The long-term outcome of the HIV/AIDS crisis is the emergence of a large population of orphaned youth or young adults due to the natural maturing or aging process of orphaned children [2]. The United Nations defines youth as persons between the ages of 15 and 24 years [3]. In 2011, UNICEF’s estimations indicated that 17.3 million children younger than 18 years of age lost one or both parents to HIV/AIDS related illnesses, and about 90% of these orphans were living in SSA [3]. In 2018, there were approximately 3.8 million orphans because of HIV/AIDS related deaths in South Africa [4].

Orphans have always relied on the extended family as a traditional support system for their care, but this has changed because household structures have been drastically altered by the HIV/AIDS epidemic. The clan network has collapsed and the kin support system has gradually diminished [5–8]. Consequently, communities and families find themselves ill-equipped to cope with the ever-increasing number of orphans in countries experiencing high prevalence of HIV/AIDS, high levels of poverty, and HIV/AIDS related stigma [8, 9]. Due to limited resources, poverty, and the high number of HIV/AIDS related deaths, the extended family is unable to cope with this role and finds it difficult to integrate the orphans into their own families as this may deplete their own resources [8, 10]. Furthermore, UNICEF maintains that the successive loss of multiple family members to HIV/AIDS has led to the gradual erosion extended family safety net of the children [5].

The collapse of the network and kin support system has given rise to the existence of child and youth headed households [8], a common and integral part of South Africa society [7]. Typically, in a child or youth headed household, the main caregiver is younger than 18 years of age. Usually this is the older sibling who takes on the responsibilities commonly assumed by parents to take care of younger siblings after the death of the mother or both parents. van der Mark [7] speaks of the ‘sibling headed households’ concept and argues that some families are being headed by siblings who have turned 18 years and are officially no longer regarded as child headed households anymore. Other researchers refer to this concept as a ‘youth headed household [11]. Nevertheless, in many parts of SSA, orphans continue being cared for by elderly female caregivers, particularly maternal grandparents [12, 13]. The presence of extended families enables orphans to receive support and withstand severe psychological stress [14].

The literature indicates that orphans experience emotional and psychological distress following the deaths of their parents, which leads to their poverty, their exploitation in the homes of their relatives, and their loss of educational opportunities [15]. The emerging evidence suggests that older orphans are at risk of poorer psychosocial outcomes [11], as the negative mental health outcomes amongst orphans are maintained and worsen into later adolescence [16]. Furthermore, older orphans have higher risk of school dropout which is heightened by lack of kin support [17–19]. Different reasons for the high risk of school dropout are documented. For example, being a maternal orphan renders a child nutritionally vulnerable and susceptible to school dropout [20], and when orphans are in child or youth headed households they are more likely to suffer negative impacts on their educational needs [7, 21, 22]. Older siblings in particular drop out of school to find employment in order to take care of the younger siblings [8, 13, 23, 24].

The death of a parent gives rise to emotional distress. The orphans are susceptible to long-term psychological problems including depression, anger, anxiety, and feelings of sadness, and are inclined to withdraw and self-isolate. These psychological problems are brought about by their failure to deal with their sense of loss [17, 25–27]. Those living in child or youth headed households experience hidden grief manifested as a prolonged bereavement [28]. One other key challenge and source of distress to orphans heading households is to adjust to the role of taking care of their siblings unprepared and with no kin support [29, 30].

Much focus has been given to the challenges of orphans in child or youth headed households depicting them as vulnerable due to HIV/AIDS [25]. Lethale and Pillay [31] argue that literature tends to portray a bleak picture of the experiences of orphans in these households even though evidence suggests that some display strong resilience in their academic and personal lives despite the odds. Resilience is defined as the positive adjustment in the context of significant adversity, or risk factors that are known to be associated with negative outcomes [32]. In the context of orphans, resilience is a positive adaptation or a useful weapon for survival following parental death [33]. There’s evidence that, although orphans in child or youth headed households experience lack of food security, poverty, and strained extended family relations, they are resilient and become independent agents and decision makers in their own right [34, 35].

Previous work on orphans in South Africa has focussed on describing their material needs and living arrangements [36]. Literature on the well-being of orphaned youth, in particular, is scanty. Moreover, the emergence of a large population of orphaned youth or young adults due to the natural maturing process of orphaned children [2] calls for an urgent need to understand their unique experiences. Notwithstanding that orphaned youth face more negative challenges than their younger counterparts do because they have been stripped of eligibility for the interventions available for younger orphans [11]. For example, in South Africa, the social grant system is withdrawn from HIV orphans when they reach the threshold of 18 years despite their precarious circumstances such as being the head of their households. Furthermore, research has established a high risk of school dropout among this population [17–19].

This paper describes how experiencing maternal death affects the psychosocial wellbeing of orphans who dropped out of school after the death of their mothers as informed by their own narratives. There is a need to understand how orphan-hood impacts on their psychosocial wellbeing in order to develop context based interventions to address their wellbeing. This is crucial in a country with 3.8 million HIV/AIDS orphans, and child and youth headed households [8] being a common and integral part of society [7].

Methods

Results

Demographic characteristics of the participants

The ages of the 50 participants that were interviewed, ranged from 18 to 24 years with a mean age of 22 years (Standard deviation = 1 year). Most of them (68%) were female (n = 34). Half of them (n = 25) lived with grandparents in extended family households and 32% (n = 32) lived with siblings. Despite most of them living with adult family members in the household, almost a quarter 24% (n = 12) were responsible for their own care (Table 1).

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Table 1. Sociodemographics of orphaned early school leavers (n = 50).

https://doi.org/10.1371/journal.pone.0229487.t001

Table 2 presents data on the age, gender, and grade in which the participants left school. More (34) females than boys are early school leavers (34 vs. 16), and 43 out of 50 dropped out in high school. More than half (27) were between the ages of 15–18 years when they dropped out of school and 23 were aged above 18 years when they dropped out. Almost all (40) reported to have repeated at least one grade.

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Table 2. School dropout profile of participants.

https://doi.org/10.1371/journal.pone.0229487.t002

Discussion

The study aimed to explore how maternal death affects the psychosocial wellbeing of orphaned youth. We found that the participants lived in socially depressed environments characterised by absolute poverty [7, 19]. The only source of income for most of the households where they lived was the old age pension grants of their elderly relatives. All the participants were 18 years and older, which is the cut-off age for receiving child social grants in South Africa. This meant that they had no financial means of taking care of themselves except in rare instances where they performed menial casual jobs. Those who had assumed the role of taking care of their younger siblings relied on meagre social grants received on behalf of their siblings. The financial constraints observed in this study are consistent with those found in other studies [49–51]. Research has established the fact that poverty is a key cause of distress among orphans, likely leading to emotional and behavioural distress [51].

The study revealed that lack of traditional kin support increased material deprivation of the participants, as 21 orphans were household heads. Equally, those who stayed with extended families (25) lived with elderly relatives in intergenerational households. In such a household, the elders stay with the adults and young children and provide for their households by using their old-age social grants [52]. It is in these households that the participants were often subjected to unequal and unfair treatment, compared with other children in the household [35]. The unfair treatment included verbal abuse; for example, one orphan was told, to go and ask for the things that she needed from her mother in the graveyard. This kind of treatment is termed an “unsympathetic gesture” made by those who care for the orphans and is associated with increased emotional and social problems in orphans [53, 54]. The current study and others [55–58] found that such unequal treatment and gestures trigger emotional pain and feelings of being unloved. It is important that children are prepared for parental death so that they are less traumatised by the experience and are able to cope with it better [35].

The narratives revealed increased levels of psychological distress manifested in prolonged pain, despondency, hopelessness, anxiety and prolonged bereavement. It is an expectation in society that grieving individuals, including children, go through a number of stages such as feelings of shock, denial, sadness, anger, anxiety, guilt and, in the end, acceptance [59]. However, their narratives showed a preoccupation with the death of the mother, despite the length of the period of her death. They found it difficult to accept the death of the mother and often wondered how they were going to make it through life without her [51]. In the current study, this was reflected in repeated statements preceded by words such as “If my mother was alive…”

In addition, they feared for their future and experienced a lack of peace long after the death of the mother. A similar observation was reported by Runhare and Gordon [28] who stated that orphans experience hidden grief, which manifested in recollections about their late parents, deep sadness and a lack of peace. Likewise, fear and lack of peace were among the negative emotions experienced by orphans in studies conducted in Zimbabwe [60, 61].

The narratives revealed that the participants used silence as a coping strategy although it is a negative coping mechanism. They spoke of bottling up their feelings when it comes to matters relating to the death of the mother. It is worth noting that they are from the same households and society that are characterised by a culture of silence, and the adoption of this behaviour of silence is explained as children mimicking the behaviour of the adults around them [62]. Nevertheless, research shows that denying children an opportunity to express their emotions results in negative manifestation of feelings characterised by anger, frustration and anxiety [35, 63]. The participants in the current study expressed the same emotions. The findings suggest that it is important to provide psychological services for orphans immediately following the death of a parent. However, such services should be culturally appropriate and be provided to extended family members in the households.

Food insecurity was one of the major problems experienced by the participants, and hunger played a big role in their lives. They were repeatedly subjected to hunger at home and sometimes had to go to bed hungry. This finding correlates with that in the literature, which reports that orphans frequently go to bed hungry, which places them at risk of mental distress [64]. Hunger was a source of pain and sadness for them, and their narratives revealed that having to go to school on an empty stomach and experiencing frequent hunger drove some of them to leave school early. They told how hunger affected their concentration at school, which resulted in poor school performance. This is consistent with other studies in SSA which highlighted that hunger affected the educational performance of orphans negatively [7, 22]. Most of the participants (40 of the 50) had repeated at least one grade, whereas nineteen had repeated more than once. It should be noted that the hunger that force them out of school continued after they left school, more so because they remained unemployed.

Early school leaving is associated with psychological distress among orphans [26, 51]. The study found that leaving school early induced emotional distress for the participants. Their narratives showed that they worry about not being in school and felt that there was no hope in their future because they had dropped out of school. There is evidence that education increases children’s survival and development prospects [65]. Therefore, early school leaving has negative implications for future economic development as it reduces employment opportunities. Of public health concern is that education is one of the strongest predictors of long-term health and health services utilization. This suggest that reduced number of years in schooling increases levels of risky health behaviours [66, 67]. In the context of HIV/AIDS, the school may be the one place where children can obtain accurate information about HIV prevention, as well as life skills that empower them to resist unwanted sex and early marriage [65]. Without valuable life-skills, out-of-school orphans are more likely to face social, psychological, economic and health problems as they grow up [68].

Conclusion

Maternal death has a negative impact on the psychosocial wellbeing of the participants even after they crossed the 18 years threshold of orphan hood resulting in the development of internalising depressive symptoms. They suffer from emotional distress and prolonged bereavement characterised by perpetual yearning for their mothers which negatively affected their ability to develop coping strategies. They resorted to silence as the only coping strategy, and that further exacerbated their emotional distress and led to isolation, sadness, hopelessness, fear and lack of peace.

Dropping out of school was also a major stressor in their lives and contributed to their poor psychosocial wellbeing. Moreover, the state of their living conditions was overwhelming and they foresaw no opportunity for them to complete school.

The study found that in this setting, the extended family still plays a role in the care of orphans in spite of the socially depressed environment where most of the households belong. Therefore, it is important to consider this when interventions are developed to address the needs of orphans.

It is important that the relevant policies should include the continuation of support for those over the age of the 18 years threshold who experience maternal death–the same as for children or adolescents. In light of the withdrawal of the social grant system for this group of orphans, NGOs and community networks should play a key role in material and emotional support in a sustainable manner through government funding. There is need for interventions that will improve their skills to prepare them for the job market or self-employment. This could be achieved through the Technical and Vocational Education and Training Colleges.

Although the study population consisted of early school leavers, the proposed intervention should also focus on orphans who are still in school to mitigate the risk of leaving school early before completing high school. The school is in a position to mitigate against issues like poor academic performance, high levels of psychosocial distress, and early school leaving among orphans.

The lack of routine screening for mental health of orphans in South Africa increases their vulnerability to undiagnosed depression. While this is not the competency of the school, the school health services presently being offered in South Africa have a critical role to play in the development of interventions for the mental health screening of orphans in schools. It is crucial that the school health services further provide counselling services to assist learners to deal with problems that affect their educational performance like the death of a parent and other related psychosocial emergencies.

Schools can also play a part in providing for this support by empowering the teachers with skills to identify orphans who are at risk and refer to appropriate service provides such as social workers, psychologists, and other social services. There is substantive evidence that teacher are more likely to support orphans when they know about their living circumstances. One of the key challenges of orphans is lack of support in getting their homework done; the school could provide space, resources, and support in this regard.

Acknowledgments

The authors appreciate the support from the schools, educators, and community based organizations that facilitated data collection. We also thank the University Research Development Grant for financially support that was granted to the first author.