title: Communication about HIV and death: Maternal reports of primary school-aged children's questions after maternal HIV disclosure in rural South Africa.
abstract: Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health.
  
  
  
  HIV-infected mothers (N = 281) were supported to disclose their HIV status to their children (6-10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1-2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline.
  
  
  
  Children's questions were grouped into three themes: 'threats'; 'implications' and 'clarifications'. Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother (AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being "frightened" (AOR 6.57 [CI 2.75, 15.70] p=<0.001) and level of disclosure (full/partial) to the child (AOR 2.55 [CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β -0.096 SE1.366 t = -0.07 p = 0.944).
  
  
  
  The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report.
  
  
  
  In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience.
authors.affiliation: Africa Health Research Institute, University of KwaZulu-Natal, South Africa; Human and Social Development Research Programme, Human Sciences Research Council, South Africa; MRC/Developmental Pathways to Health Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, South Africa; Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, United Kingdom. Electronic address: trochat@hsrc.ac.za.
authors.forename: Tamsen J
authors.initials: TJ
authors.lastname: Rochat
authors.affiliation: Africa Health Research Institute, University of KwaZulu-Natal, South Africa.
authors.forename: Joanie
authors.initials: J
authors.lastname: Mitchell
authors.affiliation: Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
authors.forename: Anina M
authors.initials: AM
authors.lastname: Lubbe
authors.affiliation: Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, United Kingdom; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
authors.forename: Alan
authors.initials: A
authors.lastname: Stein
authors.affiliation: Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
authors.forename: Mark
authors.initials: M
authors.lastname: Tomlinson
authors.affiliation: Africa Health Research Institute, University of KwaZulu-Natal, South Africa; School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Royal Hospital for Sick Children, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Ruth M
authors.initials: RM
authors.lastname: Bland
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002652:Child Behavior / Q000523:psychology; D003142:Communication; D003643:Death; D005260:Female; D015658:HIV Infections / Q000523:psychology*; D006801:Humans; D008297:Male; D063130:Maternal Death / Q000523:psychology; D008875:Middle Aged; D009034:Mother-Child Relations; D009035:Mothers / Q000523:psychology*; D036301:Qualitative Research; D012424:Rural Population; D013019:South Africa; D014342:Truth Disclosure
keywords: Children; Death; HIV disclosure; Questions