ARTICLES

 

The contribution of community volunteers in foster care placements of children living with HIV: towards comprehensive and sustainable services

 

 

Jeffries Zwelithini Khosa^I; Priscilla Gutura^II

^IUniversity of Pretoria, Department of Social Work and Criminology, Pretoria, South Africa https://orcid.org/0000-0003-0572-3569 jyvaro@gmail.com
^IIUniversity of Pretoria, Department of Social Work and Criminology, Pretoria, South Africa https://orcid.org/0000-0002-7135-6210 priscilla.gutura@up.ac.za

 

 

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ABSTRACT

This article discusses the importance of involving community volunteers to contribute towards meeting the needs of children in foster care living with HIV. This discussion is anchored in Abraham Maslow's theory of the hierarchy of human needs. The findings presented in this article emanated from a broader study that was conducted in the City of Johannesburg with social workers and community volunteers. This article discusses qualitative results which were derived from the semi-structured interviews conducted with community volunteers consisting of eight social auxiliary workers and twelve community caregivers. The participants were selected from drop-in centres using a purposive sampling strategy. The data collected were analysed thematically. The findings revealed that community volunteers offered services such as food/nutrition services, home visits, psychosocial support, homework assistance, HIV support groups, HIV adherence programmes and linking children living with HIV to care. However, very few children who were in foster care placements benefited from these services. It is concluded that the programmes rendered by community volunteers were unable to attract children in foster care, despite the children needing these services. Therefore, the study recommends a collaboration between foster care social workers and community volunteers for children in foster care to benefit from these services.

Keywords: children living with HIV; community volunteers; contributions; foster care; social workers; sustainable services

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INTRODUCTION

Foster care placements of children living with the human immunodeficiency virus (HIV) are characterised by a number of challenges. Among these challenges is the fact that it is difficult to secure placements with foster parents who are more appropriately suited to meeting the developmental needs of these children (Dhludhlu & Lombard, 2017). This is a consequence of the common traditional African practice that when parents pass on, the family nominate a person who takes responsibility for the children and the first preference is mostly the grandmothers or aunts, particularly from the maternal side. In most cases, the family does not take into consideration the developmental needs of the child. The priority is to keep the child within the family and familiar environment (Sitienei & Pillay, 2019).

This traditional approach has repercussions particularly with regard to the wellbeing of children living with HIV. For example, children may lose educational opportunities or the chance to gain accurate information about their sickness (Kibachio & Mutie, 2018). Additionally, foster parents may be overwhelmed by the responsibility of fostering and having to focus on their health. This has led to the conclusion that raising foster children has an impact on foster parents' mental health (Casale et al., 2014). Furthermore, Masha and Botha (2021) found that children in foster care experience physical neglect and abuse; Shubber and Ford (2021) add that this situation also results in the children experiencing challenges with adherence to antiretroviral therapy (ART).

From an international viewpoint, in the United States of America it emerged that foster care children are not well looked after. Furthermore, government and welfare organisations are accused of paying less attention to these children (Cooper, 2013). In Brazil the study by Pessoa et al. (2018) posits that logically it is expected that foster care children would be cared for by the foster care institutions, but found that research demonstrates that the risk of vulnerability of foster care children increases after their placement in foster care.

Spain views kinship fostering as one of the best options for children's stability and wellbeing, as it allows them to be part of a family environment, where they may receive the care and attention they require for proper development. Non-kinship placement is considered if kinship family placement is not successful (Bernedo et al., 2016). However, non-kinship foster care has become so popular in the past two decades that it is considered sound alternative care for foster care placements. Spain's foster care system is similar to the South African approach, especially as far as non-kinship placement is gaining popularity in Spain.

The health and quality of life of children living with HIV are compromised by their HIV status and the loss of parents. A study in Southern India was conducted to compare the health-related quality of life of foster care children living with HIV to that of children who reside in their own homes (Gopakumar et al., 2018). The study found, in contrast to earlier studies, that the total health-related quality of life for children living in foster homes and those living in their own homes was unaffected in any of the domains of life, whether the children lived in their own house or in foster homes. The mean total health-related quality of life was considerably higher for children in foster homes, according to the child's self-report (Gopakumar et al., 2018). This tells a story about foster care in Southern India; the findings were supported by the argument that most foster children were placed with highly educated families and exposed to good education and quality of life in general. This is not like the South African context, where children in foster care are placed with elderly people who can barely afford to meet their own basic needs and rely on foster care grants to provide for these children (Dhludhlu & Lombard, 2017; Mtshali, 2016; Phetlhu & Watson, 2014). Consequently, the need for support of children in foster care and their foster parents is apparent.

Since most foster care placements are finalised with grandmothers who are old, because of intergenerational gap, the children under their care may be unable to access some basic assistance with their schoolwork or for their sickness if they are living with HIV (Dhludhlu & Lombard, 2017; Kibachio & Mutie, 2018; Mtshali, 2016). Furthermore, some cannot even monitor whether the children are adhering to treatment or not (Mtshali, 2016). Therefore, most children in foster care remain vulnerable (Phetlhu & Watson, 2014). Furthermore, social workers are not able to monitor foster children regularly, for example, ensuring that the children adhere to treatment, receive helpful homework assistance and receive appropriate education timeously about their HIV status. Previous research has shown that social workers cited high caseloads as the reason for the untimely services to children in foster care living with HIV (Frood & Purssell, 2020; Hope & van Wyk, 2017). Given all these challenges evident in foster care placements of children living with HIV, in essence it means that foster parents require support in order to properly provide adequate fostering services. It has also been found that children with unique needs, such as those living with HIV, require more individualised assistance. Saarnik (2021) posits that caseworkers' and community volunteers' assistance is crucial to the success of foster care placements. However, there have been challenges from the social workers' side preventing them from providing adequate services, as they have been accused of not providing timely supervision in foster care (Ntshongwana & Tanga, 2018; Stone, 2014). This article explores the contribution that could be made by social auxiliary workers and community caregivers (who are referred to as community volunteers for the purposes of this study) in foster care placements for children living with HIV, where social workers' capacities are constrained. The study focused on examining the role played by community volunteers in assisting children living with HIV, their views about the vulnerability of children in foster care living with HIV, and the nature of their relationship with foster care social workers.

 

LITERATURE REVIEW

Previous studies have shown that foster parents for children living with HIV are faced with many challenges. Warwick (2013) highlighted many obstacles that foster parents of children living with HIV must overcome. These included financial challenges, having to deal with two diagnoses, stigma and anxiety, taking care of one's own physical and mental health, managing medication, and addressing the emotional distress of the foster child. Casale et al. (2014) argued that foster parents exhibit stress which can also arise from caring for children living with HIV, particularly in challenging socioeconomic circumstances. Furthermore, children in foster care are more likely to have behavioural issues which can impact negatively on the foster parents' physical and mental health (Ntshongwana & Tanga, 2018). Mark et al. (2018) argued that treatment adherence and retention of children depend on the resources, willingness and capacity of caregivers to support their care. Ntshongwana and Tanga (2018) mentioned that another challenge faced by foster parents is the poor relationship between social workers and foster parents. Lack of interaction between the foster parents and social workers affects this relationship, which compromises the services provided to children in foster care. This has been linked to challenges that social workers also face, which range from high caseloads to lack of adequate resources.

In terms of their illness, children in foster care living with HIV must develop a greater awareness of their illness, which will help them to avoid negative self-images and stick to life-saving treatments. But the process of disclosing the HIV status to the children is typically stressful for foster parents (Lowenthal et al., 2014). This may lead to limited disclosure to the children about their status. Also, the foster parents' lack of knowledge about HIV can explain the limited disclosure. Vreeman et al. (2013) argued that foster parents may not be able to deal with the follow-up questions after disclosure; hence the anxiety of foster parents contributes to non-disclosure.

Early parent loss increases a child's risk of developing an attachment problem. Breckenridge et al. (2019) stated that avoidant, self-isolating, resistant or disorganised/disoriented attachment are examples of this. This could give rise to suicidal thoughts. As orphaned children grow older, giving them access to support groups may help to ease some of the underlying emotional concerns and curb any self-destructive behaviours or deviance that may arise as a result of the underlying emotions, according to Breckenridge et al. (2019). Thus, it is important to devote careful attention to children who are living with HIV.

Cluver et al. (2012) and Le Prevost et.al. (2018) found that children who are orphaned as a result of HIV and also diagnosed as HIV positive are more likely to have challenges such as depression, anxiety and trauma than other orphans. This is a clear indication that these children require greater care and protection than other orphans. This also implies that the foster care system's umbrella approach will not be adequate to fairly meet the needs of children in foster care living with HIV. As a result, it is critical to determine specifically how to best meet the requirements of children in foster care living with HIV. According to a study by Nduwimana et al. (2017), foster parents who are caring for children in foster care living with HIV should get support from medical professionals as well as from additional social service programmes to make sure they are prepared to care for these children. Additionally, social support for foster families impacted by HIV/AIDS is considered a source of mental health wellness for both the foster parents and the foster children (Casale et al., 2014; Caserta et al., 2017).

From what the literature has shown about the experiences of both the children and foster parents, it is evident that they are overwhelmed by numerous challenges. For example, Dhludhlu and Lombard (2017), Kibachio and Mutie (2018) and Mtshali (2016) indicated that foster parents are experiencing problems within their responsibilities of fostering children living with HIV, which include understanding basic information about HIV. Furthermore, the contention that the social workers are overwhelmed by their caseloads suggests that foster care placement does not mean that children will be secure or well taken care of by the system of foster care placement. This means it is necessary to rethink the possible ways to strengthen the foster care placement of children living with HIV. The literature indicates that there are studies which contend that placing children in community-based organisations helps them to deal with life's challenges. In a study that was carried out in Kenya to examine the services that the community-based organisations provide to the orphan and vulnerable children, it was found that the children received important services from the community-based organisations that they were unable to obtain from their communities, foster homes or schools. These services included social, educational and psychological assistance (Sitienei & Pillay, 2019). Regardless of their own challenges, these programmes are crucial in maintaining children's sense of self-worth. It is also maintained that being involved with community-based organisations assisted children in meeting the basic needs as posited by Abraham Maslow's hierarchy of needs, with levels of needs from the physiological, safety, love and belonging, self-esteem to the pinnacle of self-actualisation.

In South Africa, Thupayagale-Tshweneagae and Mokomane (2014) conducted a qualitative study which evaluated the efficacy of BAR ("Better Accept Reality"), a peer-based mental health support programme for children orphaned by AIDS in South Africa. The findings of the study indicated that the programme helped the children in foster care who participated to accept the realities of their lives and as a result their relationships with foster parents improved. This is confirmed in the study conducted by Sitienei and Pillay (2019), which asserted that the support received by children living with HIV from the community volunteers in community-based organisations helped these children to become resilient.

Research has demonstrated that the likelihood of domestic disputes, abuse or violence was low among children living with HIV, who actively benefited from the services provided by community volunteers from the community-based organisations (Sherr et al., 2016). Caregivers who participated in community-based organisations' programmes were also more likely to refrain from using harsh discipline techniques on children under their care. As a result, community-based organisations' programmes were essential for boosting children's sense of self-worth and supporting foster parents in managing the medical needs of children living with HIV. Muchacha and Matsika (2017) posited that community-based care is crucial for addressing the needs of orphaned and vulnerable children. The study compared the outcomes of the orphaned and vulnerable children who received services from community-based care with other children who did not receive services in South Africa and Malawi.

From the literature reviewed above, it can be concluded that foster parents are experiencing problems within their responsibilities of fostering children living with HIV. The aim of foster placement is to create stability in the life of children and possibly close the gap left by the passing of biological parent/s. But the literature has shown that these children encounter numerous problems such as depression, anxiety, trauma, lack of awareness of their sickness, and lack of support in their schoolwork, which compromises the purpose of foster care placement. However, some studies also showed that the services provided by the community volunteers to orphan and vulnerable children are well aligned with the needs of foster care children. These studies focused on the children orphaned by HIV living in communities and not those living with HIV and in foster care placements. This study focused on foster placements of children living with HIV.

 

THEORETICAL FRAMEWORK

The theory applied in this study is Abraham Maslow's theory of hierarchy of human needs. Abraham Maslow (1908-1970) developed the theory of the hierarchy of needs in 1954 to describe why people do what they do. His argument proposed that before pursuing higher social, emotional and self-actualising needs, people have a set of basic needs that need to be satisfied, which includes, food, water, sleep, sex, homeostasis and excretion (Maslow & Lewis, 1987).

Linking that theory to this study, the argument regarding the orphan children is that their hierarchy of needs is asymmetrical, because there are many obstacles preventing the basic needs from being satisfied. The children in foster care, who may not be able to meet their physiological needs because of dysfunctional foster care placements, may consequently fail to concentrate on other needs. For example, such children may fail to concentrate at school because they are worried about their physiological needs. This kind of foster care placement is addressed in the study by Böning and Ferreira (2013). The foster parents were accused of using the foster care grant for their own enrichment instead of addressing the basic needs of the children. In such cases, Maslow would argue that children's physiological needs may not be satisfied, so as a result child may fail to attend school, or if they do, their concentration will be impaired since their minds will be preoccupied with satisfying physiological needs. Consequently, children's academic achievements will be affected.

Children need a more secure environment, where they may move around and play freely and feel confident about their safety in the future (Maslow & Lewis, 1987). For children in foster care living with HIV, this condition may be achievable when they are placed with foster parents who are aware of their developmental needs. In cases where the foster parents' capacity is not aligned with the children's developmental needs, an enabling supportive environment must be created to strengthen the foster care placement.

Children in foster care also deserve affection, which is Maslow's third level in the hierarchy of needs. According to Maslow and Lewis (1987), love is essential for all humans to survive and thrive. Furthermore, self-esteem may increase or decrease based on the nature of the support system in place. Since foster care social workers are accused of not paying appropriate attention to children in foster care, this means community volunteers need to provide the necessary support to children living with HIV in foster care placements. The literature has shown that community volunteers play a tremendously important role in helping children to meet their basic needs, which include social, nutritional, educational and psychological needs in peer-based mental health support programmes (Sitienei & Pillay, 2019; Thupayagale-Tshweneagae & Mokomane, 2014). Maslow's theory will help to understand how the community volunteers' services to children in foster care placements can assist children to meet their needs.

 

RESEARCH METHODOLOGY

Research approach

A qualitative research approach was employed in this study. Qualitative research is the systematic investigation of social phenomena in the natural environment. These phenomena may include, but are not limited to, how people perceive different aspects of their lives, how people behave individually or in groups, how businesses run, and how interactions affect interpersonal relationships (Maree & Pietersen, 2020) This approach was appropriate for this study since the study aimed to explore the contribution that could be made by community volunteers in foster care placements of children living with HIV.

Research design

The study adopted a case study design; the case study method explores a real-life, contemporary bounded system (a case). Creswell (2018) defined a case study as an intensive, holistic description and analysis of a single instance, phenomenon, or social unit. Case studies have four key attributes: conceptual validity, exploring causal mechanisms, modelling and assessing complex causal relations (Nieuwenhuis, 2020). These were applicable to the study since it is focused on examining the role played by community volunteers in assisting children living with HIV, their views about the vulnerability of children in foster care living with HIV, and the nature of their relationship with foster care social workers. Subsequently, when these four attributes are observed, there should be a correlation between what is measured and the conclusion in the study.

Sample and sampling

The sample in the study consisted of 20 participants consisting of eight social auxiliary workers and twelve community volunteers. The participants were selected using a purposive sampling strategy from 10 Drop-in centre (DICs) in the City of Johannesburg region D and G. This implies that the sample selection was made on the basis of the subjective judgment of the researcher (Maree & Pietersen, 2020). The following were the criteria of inclusion and exclusion.

Inclusion criteria - participants

• may be either female or male;

• must be either a social auxiliary worker or community caregiver providing services to the orphan and vulnerable children (OVC) (which includes, homework assistance, home visits, HIV adherence support programmes, and so on);

• employed in the same jurisdiction with one of the DSD service points in region D or G;

• must have at least three years' working experience within a DIC providing direct services to the OVC.

Exclusion criteria - participants

• employed for specific projects only;

• part-time volunteers;

• less than three years' working experience within a DIC providing direct services to the OVC.

Data collection

Data were collected through face-to-face interviews. A semi-structured interview guide was developed in line with the objectives of the study. A pilot study was conducted with three community volunteers who shared the same characteristics as the actual participants; they were interviewed to pre-test the interview guide to increase its validity and reliability, but their data were not used in the study. The final interview guide included the suggested modifications. The interviews were then conducted in the respective DICs, with each interview lasting between 30 to 45 minutes.

Data analysis

Data were subjected to a thematic analysis. The researchers used four steps of data analysis as detailed by Kumar (2019, p. 402). Step 1: Identify the main themes; Step 2: Assign codes to the main themes; Step 3: Classify responses under the main themes; and Step 4: Integrate themes and responses into the text of your report.

Data quality

Data quality was ensured through trustworthiness. Nieuwenhuis (2020) asserts that the term "trustworthiness" refers to the presence of the following four components: credibility, which is somewhat related to the positivist notion of internal validity; dependability, which is related to reliability; transferability, which was a type of external validity; and conformability. To increase the study's trustworthiness, the researcher took into account each of these four variables. To enhance the transferability of findings the researchers defined the following: number of organisations that participated in the study; type of people who participated; number of participants; data collection method; number and length of data-collection sessions; the time or period over which data were collected. The researchers ensured that they maintained objectivity throughout the process of data collection and observed the reliability and validity of the study.

Ethical considerations

The researchers received permission from the Department of Social Development and the 10 DICs to conduct the study in their facilities. The researchers also received ethical clearance with reference number 21818020 (HUM008/1021) from the Faculty of Humanities Research Ethics Committee at the University of Pretoria. Among the ethical principles used in the study were informed consent, voluntary participation, adherence to the Covid-19 protocol, avoidance of harm, confidentiality and anonymity.

 

FINDINGS AND DISCUSSION

The findings of the study are presented according to the themes and subthemes that emerged from the data analysis. First, the demographic information of the participants is presented.

Demographic information of participants

The demographic information of the participants is essential to understand the particulars of participants and then connecting to the responses in order to contextualise the content. Social auxiliary workers and community caregivers who worked at DICs in regions D and G of the City of Johannesburg were participants in this study. In presenting the findings, the researchers eliminated any information from the verbatim responses that would have disclosed the participants' identities in order to guarantee anonymity in presenting findings; participants are accordingly referred to as Participant 1 up to Participant 20. The DICs are referred to as DIC1 to DIC10.

In terms of the years of work experience of the community volunteers who participated in the study, the results show that majority of the participants ranged from four to eight years of work experience. those with ten years or more of work experience, were the most experienced of the participants. Five participants represented the group of participants with the least amount of experience, who had worked for three years.

 

 

Themes and subthemes

The findings are presented according to the three themes that emerged, and their sub-themes as indicated in Table 2 below.

 

 

Theme 1: Services provided by community volunteers to children living with HIV

The study's findings indicate that community volunteers offered children living with HIV a range of services, such as nutritional support, home visits and adherence support, referrals and linkages, educational and informational support, and HIV-related programmes. These services were identified as sub-themes and are discussed below.

Sub-theme 1.1: Nutritional support

Nutrition support was one of the fundamental services provided by the community volunteers. The following verbatim responses showed that community volunteers in the study provided this service.

Whenever there are food parcels, they are our first stop, you understand. So, we prioritise them first, then we come to the other beneficiaries. (Participant 6)

We know we do help them here. We give them breakfast at times and when they go to school, we give them lunch boxes like you know bread that they eat. (Participant 13)

But for now, what we are just doing is to make sure that they are taking their medication, they are getting food from the Drop-in centre. (Participant 18)

The findings showed that community volunteers in DICs provided cooked meals in the form of breakfast or lunch. In cases where community volunteers assessed a family and learned that they were struggling with food, they provided food parcels. One of the reasons for providing nutritional services, particularly for the children living with HIV, was to promote adherence to medication, since they needed to ensure that children eat something before they take their medication. The DICs are well positioned to assist children living with HIV and their foster parents with nutrition services. In terms of Maslow hierarchy of needs, food is regarded as a basic physiological need; therefore, the involvement of community volunteers in the lives of children living with HIV satisfies their physiological needs through providing nutritional services. Mampane (2017) confirms that the support provided by community volunteers in DICs includes food parcels. Furthermore, the study found that children who attended the DICs' after-school programmes received daily meals to help support them to take their medications once they had eaten something. Studies show that the nutritious food recommended for children living with HIV is more expensive than the grant allocated to children in foster care can cover (Bejane et al., 2013; Rutakumwa et al., 2015). Consequently, the meal and food parcels provided by the DICs can make a difference in satisfying the physiological needs of children in foster care living with HIV.

Sub-theme 1.2: Home visits and adherence support

All community volunteers agreed that they were providing home visits as one of the services to the children living with HIV primarily to support adherence to HIV treatment. The following was the view of one of the community volunteers regarding the support they provided to children living with HIV.

My role first of all is to make home visits regularly. Yes, I check on their wellbeing, to check whether they are adhering to treatment and then to check on those who are defaulting. (Participant 5)

Some participants indicated that they kept records of their visits (in the form of process notes) and used them to make follow-ups on the next visit. For example, Participant 12 stated the following,

It is both ways, they come if its urgent problem, whatever, then we also give them visits to check-up on them, how are they doing and write a home visits report and let them feel free around us. We don't ask any questions, they just let them talk, as I was saying that our relationship is strengthen by our communication channel

The participants indicated that they helped the children by collecting (on behalf of the clients) the medication from the clinic and further developed a strategy which helped the clients to adhere to the medication. They also monitored the viral load.

According to me, my job is to build a relationship with families. After building that relationship, I go to clinics to fetch treatment for the children. Before Ifetch the medication from the clinic, I have to do a home visit and fetch the containers of the medication so that they can count the medication and fill up on those containers. Then I go back to the households and give the grandmother the medication and draw up a schedule for them, so that they may know when exactly the child must take their medication. This is to ensure that they do not make mistakes, since elderly people forget. (Participant 7)

These findings showed the importance of home visits conducted by the community volunteers to the homes of children living with HIV. It demonstrated the role of home visits to ensure adherence to HIV treatment and suppression of viral load. This is in line with previous studies, for example, Mokwele (2016), who argued that community caregivers are regarded as prominent vehicles for providing services to people living with HIV. The strength of community caregivers was based on their ability to reach clients at their homes and assist them in obtaining medication. They also ensured that clients take the medications and adhere to the treatment regime until the viral load is suppressed. Research (Busza et al., 2018) in Zimbabwe shows that this was also the case in the study which explored the role of community health workers in improving HIV treatment outcomes in children. The studies showed that the children who were receiving home visit support from community volunteers showed high level of adherence and viral suppression (Busza et al., 2018). Home visits have been proven to be one of the most effective methods of support to people living with HIV. This shows that the children in foster care living with HIV could undoubtedly benefit from home visits support by community volunteers.

Humans seek to satisfy the need for love and belonging, according to Maslow. Everyone requires love and affection, even in the absence of other necessities. The demands for love and belonging are primarily met by family members. However, this may be affected in foster care placement, which is faced with challenges. So the home visits and support provided by the community volunteers will create a sense of belonging and love for the children since they will feel like they belong to the DIC. So, in this new family (DICs), children in foster care living with HIV will interact with numerous other children who are experiencing similar challenges. Through the home visit services provided by community volunteers, the foster family of children in foster care living with HIV will also be equipped with parenting skills in that the environment in the foster home will be set up to provide the love and care that the child requires.

Sub-theme 1.3: Referrals and linkages

The findings revealed that majority (12 out of 20) of community volunteers provided referrals and linkages to other children living with HIV. The following views were expressed by the community volunteers regarding referrals and linkages.

We do referrals for children living with HIV, if the children are not on medication, we do referrals to the clinic... that's the stakeholders that we are working with and also, we as the caregivers, we go to their house to make sure that they are taking their medication. (Participant 1)

Yes because of... if ever I refer a child, I make sure that it's going to be a successful referral when I do... if ever there's a case, we report to the police station. I make sure that it is a success. Everything like when I do with my beneficiaries, I make sure that it is a success. I do follow up every now and then. (Participant 9)

These findings highlight the importance of linkages and referrals when providing services for children living with HIV. They also show how prominent the role of the community volunteers was in the process of referring these children. Active referrals were done by the community volunteers, who took a newly tested person, an HIV positive child or a defaulter, to the clinic by hand. The goal was to ensure that these clients begin treatment and receive the necessary support to maintain adherence to HIV treatment (Hsiao et al., 2013). The referrals in the context of these findings meet the psychological needs as advocated in Maslow's hierarchy of needs.

Sub-theme 1.4: Educational and informational support

There are lots of aspects in foster care placements which necessitate educational and information support, such as the foster care needing to be finalised with elderly people who were illiterate. Most participants (14) showed that they were providing educational and informational support. For example, participants were asked about the kind of support they provided in this respect and the following was the response from one community volunteer indicating that children living with HIV received information support from community volunteers.

Ok my role as community caregiver, I have to teach children living with HIV that no matter condition, nothing has changed. He/she is the same, there's no difference. I have also to educate him/her about his status and I have to monitor him/her that he does take the medication and when it's time for him/her to go to the clinic, he's going to the clinic. And I also give them support, if they need someone to talk to, I will tell them that I'm here to talk to you. If the case is above me, I will take the child to Social Auxiliary. (Participant 1)

Participant 10 showed that educational and information support was not only limited to children in foster care, but extended to foster parents.

So, my role as a social auxiliary worker to children living with HIV is to make sure that we teach them since we have been trained about HIV and how to deal with those issues including the caregivers who are staying with those children. To make them see how to adhere to the treatment.

More than just general educational support about HIV, the community volunteers also indicated that they provided school-related educational support. The following were points made by three participants.

We assist with homework uhm... we also do the school visit. (Participant 18)

We also assist them with the schoolwork. (Participant 20)

These findings showed that children living with HIV were receiving educational and information support from the community volunteers. The educational support was taking two forms: information about HIV and school support. The findings revealed that children and parents were equipped with the information necessary to understand the meaning of living with HIV and the implication of that. This finding is in line with what Bejane et al. (2013) found, namely that the foster parents reported the challenges regarding the stage of initiating children to the ART, since most foster parents were inexperienced in dealing with children living with HIV. They expressed their concerns regarding the difference between virus complications and ART side effects. The educational support provided by the community volunteers was necessary to bridge the gap in knowledge about HIV/AIDS.

Moreover, the positive side of the findings was that the children all received school assistance from the community volunteers. These findings were consistent with those of previous studies. For example, the study conducted by Mampane (2017) described the socio-educational intervention programmes which were facilitated as after-school programmes by the community volunteers from the DICs, primarily to build or strengthen resilience, fight poverty and provide school support programmes, for example homework assistance. The findings of the present study have demonstrated that the DICs had structured programmes that catered for the OVC needs in different categories which included informational, emotional, instrumental and appraisal needs.

Learners who do not always have access to food and drink, who feel unsafe wherever they are staying, lack eagerness and motivation for learning (Navy, 2020). Therefore, these learners will experience challenges in their academic progress. However, the present study has demonstrated the importance of services provided by the community volunteers in the education of children. It was demonstrated that the physiological needs are met through supporting their nutritional services by community volunteers; their security needs are also addressed when they were placed in foster care. This suggests that the children will be able to focus more effectively on their learning, since their physiological and safety needs are being met.

Sub-theme 1.5: HIV-related programmes

The findings showed that community volunteers played a prominent role in the provision of HIV programmes to children living with HIV. They argued that they were providing structured programmes. A programme called Vhutshilo was the most dominant one from the DICs, particularly for children living with HIV. Below are comments on these programmes from the participants.

We also have programmes such as uhm... VHUTSHILO 3, whereby we educate them [children living with HIV]. It's more like a support group or rather for the beneficiaries to know their status and know how to manage HIV because it's only for them; it is focused on children living with HIV only. It's a structured intervention. (Participant 6)

The other programme was KIDZ ALIVE, which appeared to be one of the popular programmes since it was offered in all DICs that participated in the study. It was mentioned that KIDZ ALIVE was a programme designed with content specifically aimed at children living with HIV at the DICs by the community volunteers.

We have KIDS ALIVE. We have VHUTSHILO 3. It is [KIDZ ALIVE] a session for children aged 4-12 years. It's for disclosure. (Participant 7)

The findings provided information that there are programmes designed for children living with HIV in the DICs facilitated by community volunteers.. Phillips (2015) argued that enrolling children in structured programmes benefits them in most areas of their lives, particularly the OVC. These programmes were facilitated by the community volunteers from the community-based organisations like DICs. For example, the DICs participated in the implementation of the Khululeka programme. This was a structured programme which was facilitated through the Khu Kit manual guide (Phillips, 2015). The target group for this programme were OVCs aged 7-18. An evaluation study was conducted, and it was concluded that children who participated in the programme benefited in various ways which included their emotional wellbeing, social skills, awareness and knowledge of HIV, and homework assistance. The study by Khosa (2020) showed that children who participated in structured programmes facilitated by community volunteers were able to understand HIV and were able to take the HIV test; if they tested positive they could start treatment and adhere to it under supervision , as opposed to those who were not enrolled to the programmes. These programmes contribute to providing a sense of belonging and love to orphan children living with HIV. The programmes also boosted the self-confidence of children and help them to integrate well unto society and function just like any other child in community.

Theme 2: The community volunteers' views about the vulnerability of children living with HIV after their placement in foster care

The views of community volunteers about the vulnerability of children living with HIV after their placement in foster care were vital since they could inform whether they will provide services to these children or not. The findings suggest that community volunteers do view children as vulnerable, as discussed in the sub-themes below.

Sub-theme 2.1: Foster parents' wrong motives

The participants in the study indicated that children in foster care placement were vulnerable, since some foster parents assumed responsibility of fostering with the wrong motives, such as receiving the foster care grant. Below are some assertions of the participants.

I think sometimes people's intentions for becoming foster care parents might not be in the best interest of the child. Maybe they are doing it for the grant or whatever kind of selfish reasons. So, I do think that foster care children should be prioritised for those reasons. (Participant 14)

Most families only care about their money but they don't care about their vulnerability whether they've dealt with their issues of losing their parents or something. So, they are still vulnerable. (Participant 18)

Because you find other kids who are foster care children... they may be in foster care, and they get foster care grant and only to find that they are so many in the family and that money is not enough to cater for all of them. And you find that irresponsible guardian who takes this money for their own needs. (Participant 20)

The findings showed that community volunteers were of the view that the intentions of the foster care parents, which included prioritising the foster care grant over the child's welfare, were among the reasons for the vulnerability of children in foster care. These findings were consistent with the study conducted by Masha and Botha (2021), which revealed that children in foster care were experiencing physical neglect from the foster parents. The argument was that the foster parents were ignoring the basic needs of the children in foster care. This was explained as resulting from the misuse of the foster care grant by foster parents. It was found that the children had no warm clothes during winter and most of the time a child was left alone without additional clothes (Masha & Botha, 2021). The research showed that many foster parents assumed the responsibility of fostering children because they wanted the foster care grant more than caring for children (Naicker, 2021).

Sub-theme 2.2: Foster care finalised with elderly people

The other aspect that was emphasised by the participants was that foster care placements were mostly finalised with elderly people.

Because now they [the children] have to be taken care of by the extended family members or their elderly grandmothers or grandparents. uhm... so most of the time you will find that they... they are so much in need of basic things that they would've been given by their parents if they were alive or so. So now all that support that they need I think as a DIC, we try and uhm. come in so that we can be able to close that gap with services such as homework assistance as well because we all know that the elderly people cannot be able to help them with their homework most of the time. (Participant 8)

Some live with grandparents who cannot accompany them to clinic, sometimes they didn't have the money to go to the clinic. Some grandparents are too old and live with these children as they mother passed away, so we assist them to standing in the queue for too long and we encourage and remind the grandmother about the children's medication times. If possible, we go to their houses to give them medication. (Participant 17)

Research shows that most foster care placements were finalised with grandmothers who were old; so because of intergenerational gap the children under their care may be unable to access some basic assistance with their schoolwork or their sickness if they are living with HIV (Dhludhlu & Lombard, 2017). Furthermore, some cannot even monitor whether children were adhering to treatment or not (Mtshali, 2016). Therefore, most foster care children remain vulnerable since most of them are living with their grandmothers (Mtshali, 2016).

Sub-theme 2.3: HIV-positive status makes children more vulnerable

Some participants argued that children were made more vulnerable by the fact that they were living with HIV. For example, Participant 3 indicated the following,

Those children need to be prioritised and more particular those who are living with HIV. They are not more like any other children. Remember those children, they also need to dream.

Participant 8 shared similar sentiments and agreed that children were more vulnerable after the finalisation of foster care. She shared,

Yes, they are more vulnerable because even if they did find that foster care, they are still vulnerable because they are orphans and they are living with HIV. So, the vulnerability is still there. (Participant 8)

The fact that a child is diagnosed with HIV suggest that they are vulnerable even if they had parents, so, passing of biological parents worsens the situation. (Participant 20)

Vranda and Mothi (2013) point out that families with children living with HIV/AIDS were frequently faced with crises, diseases, lack of resources and social isolation, necessitating medical, psychological and social interventions. The circumstances faced by the children in foster care living with HIV necessitate a need for external support to address the pressure of ensuring the wellbeing of these children. The present study also shows that children with HIV are still vulnerable in foster care placements. There is agreement that being in foster care not only does not prevent vulnerability but also suggests there is a possibility of worsening the level of vulnerability on children.

Theme 3: Impact of relationship between community volunteers and social workers to services to children in foster care living with HIV

The findings of the study showed that the relationship between the community volunteers and social workers was characterised by challenges to the extent that it affected the children in foster care living with HIV detrimentally. This theme is discussed through two sub-themes: poor relationship between community volunteers and foster care social workers, and constraints on the relationship between foster care social workers and community volunteers.

Sub-theme 3.1: Relationship between community volunteers andfoster care social workers

The participants were asked whether there was any interaction between social workers and community volunteers about children in foster care, especially those living with HIV. The findings showed that community volunteers (15 in total) admitted that there was no relationship between themselves and social workers regarding children in foster care. They argued that in most cases they were the ones approaching the office of the social worker for assistance with cases, adding that social workers from DSD were not assisting them, so they approached the ones who were employed in the Department of Health. Community volunteers further noted that they did not even know there were social workers responsible for foster care. One of the participants responded as follows when asked whether social workers ever approached them about servicing children in foster care.

No! not really. There hasn 't been any social worker coming forward to say I've got these beneficiaries and are they on your database in your DIC. (Participant 6)

Another participant shared the following regarding their relationship with foster care social workers.

Normally we don't have that relationship with the foster care social worker, because sometimes when we find the child, maybe they are already in foster care. So, we just focus on the child. (Participant 8)

The researcher asked a participant if she had ever been in contact with foster care social workers regarding children in foster care living with HIV and she respondent and said,

Yes, I did, but the social worker from DSD was not responding, so we did referral with the social worker at health (Participant 12)

These findings provide a clear demonstration that community volunteers had no working relationship with social workers in terms of children in foster care, especially those who were living with HIV. The findings revealed that community volunteers did not even know the foster care social worker responsible for their area. When they tried to find out from the children or their foster parents about their social worker, they found that they also did not know. It appears that when social workers resign or redeployed, the clients were not notified. These findings are also evident in the literature; for example, the study conducted by Mampane and Ross (2017) revealed that most children in foster care did not know their social workers. Moreover, those who knew their social workers indicated that at times a different social worker would come and introduce him/herself as the social worker and subsequently, the concerns of clients were lack of termination with the previous social workers.

Sub-theme 3.2: Constraints on the relationship between foster care social workers and community volunteers

The few participants (seven) who mentioned that they had a working relationship with social workers indicated that their relationship was complicated. This was because when the community volunteers approached social workers for assistance in some cases, they would not respond citing high caseloads as a hurdle.

Participant 1 stated:

I once had a case of a foster care, then my social auxiliary worker wrote a referral, I think it was two years back. The DSD did not respond. When we called them and ask them why? They only told us that they have lot of work. They will attend the case when it's on top of the list because there's a lot of work for them.

Participant 14 shared the same view.

So, what is always said is that she is (the social worker) overwhelmed, or he's overwhelmed with cases. So even if you report a case now, you will be lucky to get a response or any type of assistance within this year.

Another participant emphasised that the social workers take a very long time to respond to them when they needed their assistance with cases.

The challenges mostly are about uhm... the turnaround time for getting help because you can link them to the social workers, but you find that the time for responding takes long. And then the child is still in need of a lot of things in that process. (Participant 15)

The findings indicated that the relationship between social workers and community volunteers is poor. They showed that the relationship was characterised by delays in providing services from the social workers in instances when community volunteers requested such services. Some participants showed that social workers rationalised their delay as the result of a high caseloads. These findings confirm those of previous studies such as Dhludhlu and Lombard (2017) and Harkin and Houston (2016), who argued that social workers were overwhelmed with high caseloads to such an extent that they were unable to deliver services timeously.

 

IMPLICATIONS TO SOCIAL WORK PRACTICE

A foster care social worker plays an important role in the placement of foster children in homes and ensuring their safety and wellbeing while in the foster care system. Social workers are also critical in the preparation of foster parents for their role. Findings of this study have shown that it is crucial for social workers to ensure that they prepare both the child living with HIV as well as the prospective foster parent/s before the finalisation of foster care placements to minimise the challenges that are associated with taking care of a child living with HIV. Most importantly, there is a need to monitor foster care placements consistently. However, because of the various challenges faced by social workers such as high caseloads, the comprehensive services required are often not available. The findings of this study should alert social workers to the need for serious consideration of collaborative efforts to ensure that foster care placements are monitored effectively. This involves working with different stakeholders such as DICs or other community-based organisations, where community volunteers can fill the gaps and ensure that children living with HIV who are in foster care are provided with comprehensive and sustainable services.

 

CONCLUSION

The findings have shown that community volunteers were providing services to children living with HIV. These services included home visits, referrals and linkages, educational and informational support, adherence support, HIV-related programmes and nutrition services. However, most of the clients who received these services were not children in foster care. The findings revealed that the relationship between social workers and community volunteers was poor. This was informed by the challenges raised by community volunteers regarding their interaction with social workers. It was reported that social workers did not respond to community volunteers when they requested help with clients in DICs. The social workers cited high volume of cases and backlogs as reasons for a delay in cases referred to them.

Importantly, the results also indicated that community volunteers' viewed children in foster care living with HIV as remaining vulnerable and deserving of the services offered in the DICs. Their argument was that most foster care cases were finalised with elderly people who were unable to cater for the most basic needs of children, like school homework and support in ensuring adherence to HIV treatment. The other challenge was that foster parents were undertaking fostering responsibilities for the wrong reasons, such as receiving the foster care grant. Significantly, the fact that these children were living with HIV made them vulnerable.

From the findings it can be concluded that the involvement of community volunteers in the lives of children living with HIV does address the hierarchy of needs as presented by Abraham Maslow. The services from community volunteers met needs such as the need for nutrition, a sense of belonging and psychological wellbeing, which ultimately boosted the self-esteem of children so that they became well positioned to focus on self-actualisation. Unfortunately, the programmes of community volunteers were unable to attract children in foster care, particularly those living with HIV. This could be attributed to the fact that there was no collaboration between the social workers and community volunteers in dealing with children in foster care living with HIV and there was no other alternative approach from community volunteers to reach out to children in foster care. Therefore, it is recommended that these social service providers need to work together in the best interests of children. The focus should not be on the weakness of social workers, but on how community volunteers could be involved and strengthen the services provided to children in foster care, particularly those who are living with HIV. Similarly, it is through collaboration between social workers and community volunteers that the provision of comprehensive and sustainable services can be achieved.

 

RECOMMENDATIONS

• The study recommends a partnership and collaboration between social workers and community volunteers.

• The study recommends that social work supervisors and DICs managers should promote collaboration between social workers and community volunteers to ensure comprehensive and sustainable services to children living with HIV in foster care.

• The study recommends that in the monthly report template for both the social workers and community volunteers there should be an indicator showing services they provided to children living with HIV in foster care. From social workers this can entail a referral of these children to community volunteers.

• The study recommends that social workers should finalise foster care with foster parents in a way that is aligned with the developmental needs of children. However, in cases where the finalisation of foster care placement is done with elderly foster parents, it is highly recommended that the foster family be linked to the DICs.

 

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Article received: 28/03/2024
Article accepted: 06/08/2024
Article published: 27/03/2025

 

 

AUTHOR BIOGRAPHY
Jeffries Zwelithini Khosa was a PhD candidate at the Department of Social Work and Criminology, University of Pretoria, South Africa. His field of specialisation includes child protection services. The article is based on his PhD research, conducted from January 2021 to December 2023, and its initial draft was derived from his thesis.
Priscilla Gutura is an Associate Professor at the Department of Social Work and Criminology, University of Pretoria, South Africa. Her field of specialisation includes empowering vulnerable members of society, in particular women and children, and fighting against gender-based violence. She supervised the study from 2021 to 2023 and assisted in drafting the article.