Non-enrollment in School and drop-out in the Era of
HIV care &Treatment, Rakai South-Western Uganda
A Wednesday Noon Seminar, at JHBSPH
Department of PFRH
September 25th 2013
Presenter
Fredrick Makumbi, PhD
Makerere University School of Public Health,
& The Rakai Health Sciences Program
Background
• HIV care and treatment has improved
Survival of HIV infected adults and children
Quality of life of the HIV+, and many have
rejoined the active work force
• Significant declines in the incidence of orphanhood,
and increased proportion of children born without
HIV-infection
Background
• However, data on the indirect benefits of HIV
care and treatment intervention are still
limited
• For example, the effects of HIV care services on
the rate of school enrollment or school dropout rates among children of school going age
Background
• Uganda’s Universal Primary (1996) and secondary
(2007) education Policy was introduced
• Not all children of school going age enroll in school,
or maintain their enrolment
• Although UPE policy provides free tuition to the
pupils, a number of other requirements that enable
pupils to be in school are still borne by
parents/caretakers
Background
• Factors such as household SES, parental/care takers’
health status (especially HIV/AIDS related), can lead to
non-enrollment or drop-out due to lack of some basic
school requirements or care for the sick parents
• HIV+ children may also be less likely to enroll in school
• Availability and quality of schools, as well as community
attitudes towards schooling may affect enrolment
Conceptual Framework for School enrolment, drop-out and HIV-care
Objective
• To determine the effect of parental receipt
of HIV-care services on children’s school
non-enrollment and drop-out in a rural
resource limited setting
Rakai Community Cohort study
•
•
•
•
•
Population aged 15-49 years
56 communities grouped into 11 clusters
Total population: 13,000
Composition: Rural, semi-urban, urban
Population-based surveys of the Rakai cohort have
been conducted every 12-15 months since 1994 .
Rakai
Entebbe Airport
Rakai
District
Why rural Rakai?
An HIV epicenter
D Serwadda, N Sewankambo et al first
identified “slim disease” patients in Rakai in
1982.
Chronology of RCCS activities
1. Community Mobilization
Health Education and Community Mobilization
Survey team in the field, end of day
Field-based collection of
biological samples for HIV,
STD and infectious
disease surveillance
Methods
• Annual household enumeration conducted in
the Rakai community cohort surveillance
• Data include age, sex, relationship to house
head, schooling status for the 5-22 year olds,
survival of biological and dwelling structure
to construct house-hold SES
Methods
• Adult
(15-49
years)
HIV
status
from
consenting adults
• Free HIV care and treatment services to HIV+
provide by Rakai program
Statistical analysis
• Descriptive analysis with outcome as nonenrollment in school, and drop-out
• Survey rounds R11 (Jan 2005/May 2006) to R14
(Dec 2009/May 2011) with data on outcome
• Eligible School ages 6-12 years (Primary) and
13-16 years (Secondary)
Statistical analysis
• Binary outcome thus use of logistic regression
model
• Xtlogit
model
with
robust
variance
and
unstructured covariance structure to account for
repeated measures
• Adjusted for SES, Parent’s HIV, age, HIV-care,
time(survey rounds)
FINDINGS
Characteristics of Children of school going age 6-16 years
R011
N
Overall
16,065
%
R012
N
%
R013
N
%
R014
N
%
100 17,402
100
17,203 100.0 17,025 100.0
Sex
Female
51.3
51.8
51.6
51.6
Male
48.7
48.2
48.4
48.4
6-12
66.0
67.5
67.1
67.1
13-16
School
Enrolment
34.0
32.5
32.9
32.9
Enrolled
Non-enrolled
93.0
7.0
92.8
7.2
97.7
6.0
94.4
5.6
Age(years)
Characteristics of Children of school going age 6-16 years
SES
High
Middle
Low
Orphanhood
Non-orphans
Double
Maternal-alone
Paternal-alone
R011
R012
R013
R014
%
%
%
%
40.3
30.6
29.1
42.6
30.2
27.1
44.8
31.8
23.4
49.3
31.5
19.1
73.8
7.3
5.6
13.3
77.2
6.3
4.9
11.7
79.6
4.9
4.4
11.1
82.2
3.6
4.0
10.2
Characteristics of Children of school going age 6-16 years
R011
R012
R013
R014
%
%
%
%
Both-missing
39.5
38.1
39.3
38.1
HIV-both/one missing
50.8
51.8
50.6
51.0
At least one HIV+
9.7
10.2
10.1
10.9
Not in Care
63.4
51.2
43.6
40.0
In Care
36.6
48.8
56.4
60.0
Parental HIV-status
HIV care enrolment
Summary of characteristics of Children, 6-16 years
• ~ 2/3 were primary school going age (6-12 years)
• Nearly universal enrolment, only 7% not enrolled and
declines overtime
• Over 40% in high SES and has increased to 50% in last
survey
• Orphanhood been decreasing over time, most significantly
double orphans
• Proportion with at least one HIV+ parent has been stable
over time, ~10%
• Parent’s enrolment in HIV care& treatment been
increasing
Proportion not enrolled
0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1
Trends in School non-enrollment by age eligibility
17-22 yrs
Jan 2005/
May 2006
13-16 yrs
6-12 yrs
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Dec 2009/
May 2011
Proportion not enrolled
0 .02 .04 .06 .08 .1 .12 .14 .16 .18 .2
Trends in School non-enrollment by sex
13-16 year olds
Males
Females
6-12 year olds
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Dec 2009/
May 2011
.2
Trends in school non-enrolment by Parental HIV+ status
Both unknown HIV
At least one HIV+
HIV-negative
6-12 year olds
0
Proportion not enrolled
.05
.1
.15
13-16 year olds
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Dec 2009/
May 2011
13-16 year olds
Double-orphans
Maternal
Paternal
Non-orphans
6-12 year olds
0
Proportion not enrolled
.05
.1
.15
.2
.25
Trends in School non-enrollment by Orphanhood status
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Dec 2009/
May 2011
Trends in non-enrollment in school
by children characteristics
• Non-enrollment in school is higher among older
(13-16 years) than younger (6-12 years) children
• Overall, observed declines in non-enrollment in
school over time
• Non-enrollment is significantly higher
• among males compared to girls
• Children with parents of unknown HIV status
• among orphans, in older children (13-16 years)
At least one in HIV-care
.05
.1
.15
13-16 year olds
None in HIV-care
6-12 year olds
0
Proportion not enrolled
.2
Trends in School non-enrolment by Parental HIV care
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Dec 2009/
May 2011
13-16 year olds
.15
Low
Medium
.1
High
.05
6-12 year olds
0
Proportion not enrolled
.2
.25
Trends in School non-enrollment by SES
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Dec 2009/
May 2011
Trends in non-enrollment in school
by children characteristics
• No clear association of Parental receipt of HIV care
and non-enrollment in school
• Lower SES is a significant determinant of nonenrolment in both young and older children
Adjusted OR for non-enrollment in School;
All children Combined
6-12 year olds
13-16 year olds
Parent HIV status
Adj.OR
HIV-Neg
1.0
At least 1 HIV+
0.98
0.81
1.17
1.12
0.93
1.35
Both unknown
1.28
1.13
1.45
2.22
1.99
2.47
Orphaned
1.15
0.98
1.34
1.31
1.18
1.45
Male (vs female)
1.43
1.28
1.59
1.18
1.07
1.29
Age (years)
0.62
0.59
0.64
2.17
2.08
2.26
Medium
1.95
1.70
2.23
1.42
1.28
1.57
Low
3.25
2.84
3.72
1.97
1.76
2.20
95% CI
Adj.OR
95% CI
1.0
Sex
SES (High=ref)
Adjusted OR for non-enrollment in School
among children with HIV+ parent
6-12 year olds
95% CI
13-16 year olds
HIV care
Adj.OR
Adj.OR
95% CI
Not in care
1.0
In care
0.77
0.55
1.09
0.94
0.67
1.32
Orphaned
0.87
0.57
1.34
1.12
0.80
1.58
Male (vs female)
1.57
1.12
2.21
1.70
1.21
2.41
Age (years)
0.53
0.45
0.62
2.61
2.22
3.06
Medium
2.56
1.61
4.07
1.62
1.11
2.37
Low
3.21
2.05
5.05
2.56
1.72
3.80
1.0
Sex
SES (High=ref)
13-16 year olds
Males
.1
.05
Females
6-12 year olds
0
Proportion drop-out
.15
.2
Trends in primary school dropout by gender, 6-12 years
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
.15
13-16 year olds
No known HIV Status
.1
At least one HIV+
.05
Only known HIV-
6-12 year olds
0
Proportion drop-out
.2
Trends in primary school dropout by Parental HIV-status
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
.15
13-16 year olds
.1
Parent in care
.05
Parent not in care
6-12 year olds
0
Proportion drop-out
.2
Trends in School dropout by Parent’s HIV care status
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Adjusted OR for School drop-out;
All children Combined
6-12 year olds
Parent HIV status Adj.OR
95% CI
13-16 year olds
Adj.OR
95% CI
HIV-Neg
At least 1 HIV+
1.03
0.66
1.60
1.05
0.86
1.29
Both unknown
2.46
1.92
3.16
1.27
1.12
1.44
Orphaned
1.17
0.91
1.52
1.24
1.09
1.41
Male (vs female)
1.76
1.40
2.22
1.51
1.35
1.69
Age (years)
1.42
1.33
1.53
1.48
1.41
1.56
Medium
1.49
1.11
2.00
1.86
1.62
2.14
Low
2.45
1.88
3.20
2.84
2.47
3.26
Sex
SES (High=ref)
Adjusted OR for School drop-out among children
with HIV+ parent
6-12 year olds
Not in care
Adj.OR
1.0
In care
0.50
0.21
1.18
1.41
0.98
2.04
Orphaned
1.08
0.43
2.71
0.88
0.61
1.27
Male (vs female)
3.45
1.37
8.67
1.67
1.16
2.40
Age (years)
1.14
0.92
1.43
1.51
1.29
1.76
Medium
2.18
0.73
6.51
1.27
0.83
1.96
Low
3.43
1.23
9.53
2.06
1.31
3.24
HIV care
95% CI
13-16 year olds
Adj.OR
1.0
95% CI
Sex
SES (High=ref)
When outmigration and deaths compete with
known drop-out as an outcome
6-12 year olds
13-16 year olds
Study visit
Jan 2005/
May 2006
outDied
Total migrated (%) (%)
outDied
Total migrated (%) (%)
10952
5582
Aug 2006/
Apr 2008
13750
-
-
1879(13.7) 29(0.2) 7125
-
-
1426(20.0) 9 (0.1)
May 2008/
Sept 2009 13541
1904(14.1) 21(0.2) 7021 1328 (18.9) 14 (0.2)
Dec 2009/
May 2011
1966(14.6) 25(0.2) 6838
13498
1198(17.5) 11(0.2)
.05 .1 .15 .2 .25 .3 .35 .4 .45 .5
13-16 year olds
Male
Female
6-12 year olds
0
Proportion dropout/death/outmigration
Trends in School dropout/death/outmigration by gender
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
.05 .1 .15 .2 .25 .3 .35 .4 .45 .5
Orphans
13-16 year olds
Non-orphans
6-12 year olds
0
Proportion dropout/death/outmigration
Trends in School dropout/death/outmigration by orphan-status
Jan 2005/
May 2006
Aug 2006/
Apr 2008
May 2008/
Sept 2009
0 .05 .1 .15 .2 .25 .3 .35 .4 .45 .5
Proportion dropout/death/outmigration
Trends in School dropout/death/outmigration
by parent HIV care-status
13-16 year olds
In care
6-12 year olds
Jan 2005/
May 2006
Not in care
Aug 2006/
Apr 2008
May 2008/
Sept 2009
Adjusted OR for School drop-out among
6-12 year olds children with HIV+ parent
Drop-out, only
Not in care
Adj.OR
1.0
In care
0.50
0.21
1.18
0.72
0.60
0.87
Orphaned
1.08
0.43
2.71
1.14
0.92
1.42
Male (vs female)
3.45
1.37
8.67
1.12
0.94
1.35
Age (years)
1.14
0.92
1.43
0.95
0.91
1.00
Medium
2.18
0.73
6.51
0.87
0.70
1.08
Low
3.43
1.23
9.53
0.91
0.73
1.13
HIV care
95% CI
Composite drop-out
Adj.OR
1.0
95% CI
Sex
SES (High=ref)
Adjusted OR for School drop-out among
13-16 year olds children with HIV+ parent
Drop-out, only
Not in care
Adj.OR
1.0
In care
1.41
0.98
2.04
1.12
0.87
1.43
Orphaned
0.88
0.61
1.27
1.00
0.78
1.28
Male (vs female)
1.67
1.16
2.40
0.92
0.72
1.18
Age (years)
1.51
1.29
1.76
1.23
1.11
1.37
Medium
1.27
0.83
1.96
1.12
0.83
1.52
Low
2.06
1.31
3.24
1.99
1.48
2.69
HIV care
95% CI
Composite drop-out
Adj.OR
1.0
95% CI
Sex
SES (High=ref)
Key summary findings
• Parental receipt of HIV care & treatment
services tends to be associated with lower
drop-out among younger children (6-12 years)
but not older children
Key summary findings
• School non-enrolment and drop-out are
decreasing over time
• Orphanhood, lower SES, and higher age, and
male gender are determinants of drop-out,
especially among older children
Conclusion
• In Universal Primary and Secondary education
environment, with increasing availability of HIV
care and treatment services, children’s nonenrollment and drop-out are lower when parent(s)
is in HIV care
• However,
drop-out
and
non-enrollment
are
significantly higher among boys or older children