Household illness, poverty and physical and emotional child abuse victimisation: Findings from South Africa's first prospective cohort study

Abstract

Physical and emotional abuse of children is a large scale problem in South Africa, with severe negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and emotional abuse, no research has thus far investigated the different pathways from household chronic illness to child abuse victimisation in South Africa.
Confidential self-report questionnaires using internationally utilised measures were completed by children aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person's disability as hypothesised mediators.
For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was established. For boys, positive and negative indirect effects through poverty and disability were found respectively. For girls, a negative indirect effect through poverty was observed.
These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability. Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families experiencing illness in South Africa.

Full text

R E S E A R C H A R T I C L E Open Access
Household illness, poverty and physical and
emotional child abuse victimisation: findings from
South Africa’s first prospective cohort study
Franziska Meinck
1*
, Lucie D Cluver
1,2,3
and Mark E Boyes
1,4
Abstract
Background: Physical and emotional abuse of children is a large scale problem in South Africa, with severe
negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and
emotional abuse, no research has thus far investigated the different pathways from household chronic illness to
child abuse victimisation in South Africa.
Methods: Confidential self-report questionnaires using internationally utilised measures were completed by children
aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban
locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple
mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other
illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person’s
disability as hypothesised mediators.
Results: For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive
indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of
AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty
was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was
obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was
established. For boys, positive and negative indirect effects through poverty and disability were found respectively.
For girls, a negative indirect effect through poverty was observed.
Conclusions: These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse
victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic
illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability.
Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families
experiencing illness in South Africa.
Keywords: Child abuse, Adolescent abuse, HIV/AIDS, Predictors, Risk factor, Chronic illness
* Correspondence: Franziska.Meinck@spi.ox.ac.uk
1
Centre for Evidence-Based Intervention, Department of Social Policy &
Intervention, University of Oxford, Barnett House, 32 Wellington Square,
Oxford OX1 2ER, UK
Full list of author information is available at the end of the article
© 2015 Meinck et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Meinck et al. BMC Public Health (2015) 15:444
DOI 10.1186/s12889-015-1792-4

Background
Approximately 40 million children under 14 years of age
are victims of abuse and neglect worldwide [1], with
children in the sub-Saharan African region suffering
from particularly high rates of abuse [2,3]. Explanations
for these elevated prevalence rates in Africa often lack
empirical basis. Poorly developed child protective sys-
tems, modernisation and negation of traditional values,
large numbers of orphaned children, and disruption of
community structures and social norms are some hy-
pothesised causes [4].
Illness and abuse
Like other countries in the region, South Africa is also
experiencing a considerable burden of disease, with large
numbers of people suffering from communicable (e.g.
HIV or TB) and non-communicable illnesses (e.g. high
blood pressure or diabetes) [5]. Research has shown that
violence and poor health are correlated, especially in low
and middle-income countries in Africa [6] and a recent
systematic review of correlates of child abuse victimisa-
tion in Africa found an association between household
illness and child maltreatment
a
[7]. It is, however, un-
clear whether the cross-sectional relationship between
household illness and child abuse is sustained over time
using longitudinal data. No research has thus far exam-
ined whether households with certain types of chronic
illnesses such as those related to AIDS differ in their risk
for physical and emotional child abuse victimization.
This may be due to specific direct and indirect pathways
from household chronic illness to challenges in parent-
ing within the home.
Investigating pathways to abuse
In order to understand the relationships between house-
hold illness and child abuse, it can be valuable to situate
household illness within a larger ecological model [8].
This framework places the child at the centre of multiple
interacting spheres of influence such as peers, family,
community and society. While there may be a direct effect
of household illness on child abuse, an indirect effect of
household illness on risk for child abuse victimisation
through additional factors (i.e. stress, pain, fatigue or
stigma) is probable [9].
Indirect effects of household illness on risk for child
abuse victimisation are investigated using mediators.
Mediating factors are variables which play an important
role in governing the relationship between the hypothe-
sised risk factor and outcome. As chronic illness can
affect patients differently and manifest in different ways,
some aspects of suffering from a chronic illness may be
particularly prone to affect the risk for child abuse vic-
timisation (i.e. poor mental health), while others are not.
Mediation analysis can be used to examine how these
particular aspects influence the relationship between
chronic illness and child abuse. Whether or not there is
a direct link between chronic illness and child abuse vic-
timisation, it is possible that chronic illness exacerbates
other factors which in turn increase the risk for child
maltreatment.
Linkages between poverty, disability, ill health and abuse
A recent systematic review identified household poverty
and disability as common correlates of physical and emo-
tional child abuse victimisation in Africa [7]. International
research has found strong bidirectional positive linkages
between poverty and ill health [10,11] and positive corre-
lations between child maltreatment, poverty and caregiver
ill health [12,13]. A trial of an intervention carried out in
Wisconsin with families affected by poverty showed lower
likelihood of child protection investigations in families
who received more financial support compared to those
who received less [14]. Previous studies in South Africa
have found that children in AIDS-affected families report
consistently higher levels of poverty than children in
healthy or other ill families [15,16]. Studies from the
United Kingdom suggest that parents with disabilities are
more likely to live in low-income households and to be
economically inactive [17]. In addition, parents or care-
givers with disabilities may be at greater financial disad-
vantage because they have to pay for additional support in
and outside the household and while parenting [18].
Studies from the United States found that mothers
with chronic pain reported more laissez-faire parenting
and poorer relationships with their children [19]. They
experienced more psychosocial distress, which impacted
on their parenting, in particular their ability to parent
positively [19,20]. Likewise, paternal illness predicted
negative family functioning [21] The larger the number
of stress factors (such as ill health, physical problems
and poverty) a parent experienced, the less likely they
were to cope with parenting stress [22].
However, existing evidence is thus far unclear about
the ways in which household illness, poverty, and dis-
ability link together with child abuse victimisation. A
previous cross-sectional study from South Africa found
that caregiver AIDS-illness was linked to poverty, extent
of disability of the ill person and abuse [15]. Evidence
suggests that particularly families affected by AIDS appear
to be at higher risk for child maltreatment [23], and that
those affected by other chronic illness have lower or equal
risk to those in healthy families [13]. It is unclear, however,
what the mechanisms of these relationships are.
Poverty and disability as potential mediators between
household illness and abuse
There are a number of routes by which poverty may be
increasing risk of abuse. Previous research suggests that
Meinck et al. BMC Public Health (2015) 15:444 Page 2 of 13

economic status and social support are highly correlated
with caregiver depression [24] which is further exacer-
bated by food insecurity [25]. Poverty and poor physical
health also predict increased psychological stress in kin-
ship carers [26]. In settings with high HIV-prevalence,
high levels of stress, depression and poor physical health
were found amongst adults caring for children [27]. A
previous study from South Africa found that household
AIDS-illness was associated with reduced capacity of posi-
tive parenting [28]. Research from high-income countries
also shows poorer parent-child relationships and more in-
consistent parenting amongst HIV positive parents and
those suffering from chronic pain [21,29,30].
There are also number of pathways in which disability
may be increasing risk of abuse. Previous research sug-
gests that physical disability in chronically ill patients is
highly correlated with poor mental health [31]. A larger
number of symptoms and higher extent of disability was
found to be associated with higher parental distress and
aggravation during parenting tasks [32]. Furthermore,
illness-related demands predicted lower parenting quality,
which in turn predicted child behaviour problems [33].
Household illness and high levels of disability, coupled
with stigma and poverty may therefore lead to increased
stress, poorer parenting and mental health, which can in-
crease child conduct problems, all of which have been
found to be risk factors for child maltreatment [12].
To date, the understanding of risk factors for child
maltreatment in South Africa has been limited. First, all
of the studies to date are cross-sectional in design which
limits determination of directions of association [7,34].
Second, the majority of studies used retrospective recol-
lections of childhood abuse [35,36], which may be sub-
ject to recall bias [37]. Third, samples mostly consist of
high-school and university students [38,39], which may
exclude some of the most vulnerable children who may
not be reaching these levels of education [23]. Fourth,
some studies use patient chart data from mental health
units, court records and social services [40,41] that are
subject to bias as only the most severe or most identifi-
able cases may have been reported to officials [42]. Fifth,
no published study has examined direct and indirect
pathways from household chronic illness to risk for child
abuse victimisation.
The current study therefore had two aims. First, we
aimed to determine the direct and indirect effects of
baseline household AIDS-illness on physical and emo-
tional child abuse victimisation at follow-up. Second, we
aimed to examine direct and indirect effects of baseline
other household chronic illness on physical and emo-
tional child abuse victimisation at follow-up (Figure 1).
Analyses were conducted separately for boys and girls
for emotional abuse due to significant differences in vic-
timisation between the genders.
Methods
Participants
3515 children aged 10-17 (mean age 13.5 years, 56.7%
female, 50.6% urban location) were originally recruited
between January 2010 and June 2011 in four health dis-
tricts with >30% HIV prevalence in rural and urban
areas of Mpumalanga and the Western Cape. Within
each health district, census enumeration areas were ran-
domly selected. All households with children aged 10-17
within each census enumeration area were included in
the study. One child in each household was interviewed
and where there were multiple children in the house-
hold, one was chosen at random. Between January 2011
AIDS-illness or
other-illness
Frequent
physical/emotional
abuse
Disability
Poverty
Indirect Effect
Direct effect
Indirect Effect
Figure 1 Hypothesised direct effect and partial indirect effects of household chronic illness on physical and emotional abuse.
Meinck et al. BMC Public Health (2015) 15:444 Page 3 of 13

and June 2012, 3401 participants (96.7% retention rate)
were traced and re-interviewed. Refusal rate at baseline
was 2.8% and < .5% at follow-up. Adults were not re-
cruited for this study but had to give consent for their
child’s participation.
Procedure
With interviewers, children completed an anonymous
guided 60-minute self-report questionnaire which was
translated into Xhosa, Swati, Tsonga, Sepedi and Zulu
and checked by back-translation. Interviews were carried
out in locations selected by the child in order to guaran-
tee confidentiality and privacy (e.g. under a secluded
tree, empty classrooms). Interviewers from the area re-
ceived intensive training in working with vulnerable chil-
dren and in administering standardised questionnaires.
Participation was voluntary and children were able to
stop the interview at any time. All participants received
a certificate of appreciation for taking part in the research
and light refreshments irrespective of completion of the
questionnaire. Certificates showcased international celeb-
rities on the front and contained information about the
complaints procedure of the study and contact details for
telephone helplines such as Childline, Lovelife and the
local police on the back.
Due to low literacy in the sampled population group,
information and consent sheets were read aloud to chil-
dren and their caregivers and clarification questions an-
swered until participants were satisfied and consented to
take part. Stringent quality checks were in place so that
missing data were < .05%. All survey items were pre-
piloted with vulnerable youth to investigate age appro-
priateness and cultural sensitivity. Ethical approval was
granted by the University of Oxford, University of
KwaZulu-Natal, University of Cape Town, Provincial De-
partments of Health and Education and the National
Department of Social Development.
Confidentiality was maintained throughout the study
unless participants were considered to be at risk of signifi-
cant harm or requested help, and this was clearly outlined
in the consent forms. Where this was the case, the project
manager and interviewer discussed options of referrals
with the child. Immediate referrals were made following
discussion with participants to local child protection ser-
vices for children experiencing ongoing severe abuse.
Where children had experienced abuse in the past, refer-
rals to counselling centres and HIV-testing services were
made where appropriate and requested. 145 referrals were
made at baseline, 664 referrals were made at follow-up.
Measures
All measures of abuse were pre-piloted and modified to
fit the cultural context with the help of experienced so-
cial workers, child protection NGOs and vulnerable
children in South Africa.The whole abuse scale showed
good reliability in this sample (α= .73). Child physical
and emotional abuse victimisation at follow-up were
measured using seven items from the UNICEF Measures
for National-Level Monitoring of Orphans and other
Vulnerable Children [43] that are based on the Conflict
Tactic Scales for Parent and Child (CTSPC) [44]. The
CTSPC has been used in international studies across the
world [45,46]. The UNICEF measure has not been vali-
dated in South Africa but was successfully used in an-
other study in the Western Cape with good reliability
(α= .70) [23]. Seven additional items were devised through
qualitative pre-piloting with practitioners and vulnerable
children (α= .74 for all 14 items on this subscale). Past-
year frequency of abuse was measured (0: never; 1: not in
the last year; 2: at least once this year; 3: month; 4: weekly).
A conservative threshold for frequent abuse was set as
occurrence of physical or emotional abuse on a monthly
or more frequent basis within the last year (see Additional
file 1 for complete list of items and Additional file 2 for
the original response values) and a dichotomous variable
was created for physical and emotional abuse respectively
(0: no monthly abuse; 1: yes monthly abuse).
Household chronic illness and extent of disability were
measured using a Verbal Autopsy Checklist [47], which
included symptoms of AIDS-related and other chronic
illnesses common in South Africa such as diabetes, high
blood pressure, arthritis, alcoholism, emotional problems,
and cancer [48]. The Verbal Autopsy has been validated in
South Africa [49] and was applied to all household mem-
bers who had been ill for a period of at least two weeks.
Determination of household AIDS-illness required identi-
fication of three or more AIDS-defining illnesses (i.e.
HIV-wasting syndrome, Kaposi sarcoma, oral candidiasis,
vaginal cancer, jaundice or herpes zoster). Dichotomous
variables were created for household AIDS-illness (0: not
ill with AIDS; 1: ill with AIDS) and other chronic illness
(0: not ill with other chronic illness; 1: ill with other chronic
illness). Extent of the ill person’s disability was measured
using 7-items from the WHO International Classification
of Functioning, Disability and Health ‘activity limitation
and participation’sub-scale [50]. Example items include
difficulty of carrying shopping or carrying out personal hy-
giene, and are responded to according to level of difficulty
(0: not at all difficult; 1: a little difficult; 2: very difficult; 3:
not able to do it). Items were summed to give a total dis-
ability score. The scale showed good reliability in this sam-
ple α=.93.
Household poverty was measured using an index of ac-
cess to the eight highest socially-perceived necessities
for children in South Africa [51], which showed good re-
liability of α= .80 in this sample. Necessities included:
enough clothes to remain warm and dry, soap to wash
every day, three meals per day, a visit to the doctor and
Meinck et al. BMC Public Health (2015) 15:444 Page 4 of 13

medicines when needed, school uniform, money for
school fees and more than one pair of shoes. Items were
reverse scored (0: has access to item; 1: does not have ac-
cess to item) and summed to give a total poverty score (i.e.
total number of necessities lacking).
Demographic covariates of gender, age, receipt of pen-
sion, formal/informal housing and urban/rural location
were measured using items modelled on the South African
Census [52].
Analysis Analyses were conducted in three stages, using
SPSS 20. First, differences in socio-demographic character-
istics and physical and emotional abuse victimisation be-
tween children lost (n = 114) and retained (n = 3401) at
follow-up were investigated. Second, descriptive analyses
and comparison of means (ANOVA) investigating relation-
ships between gender, illness-status, disability and poverty
were carried out. Third, multiple mediation tests using
OLS for and logistic regression analyses for dichotomous
outcomes with the PROCESS macro [53] were conducted
to determine direct and indirect effects of chronic house-
hold illness on child abuse victimisation. Other than Baron
& Kenny [54], Hayes [55] and Zhao, Lynch, & Chen [56]
do not require that two variables have to be associated with
each other in order to test hypotheses of indirect effects.
Multiple mediation analyses used Preacher and Hayes’
[57] bootstrapping procedure. This is a nonparametric
sampling procedure recommended for simultaneous
testing for indirect effects of multiple mediators [58]. It
allows determination of the extent to which each mediator
variable affects the relationship between the hypothesised
predictor and the outcome in the presence of other poten-
tial mediators. Tests for significant mediation required
bias-corrected 95% confidence intervals to not overlap
zero, based on 1000 bootstrap samples. Mediation ana-
lyses investigating emotional abuse were conducted separ-
ately for boys and girls considering a higher risk for
emotional abuse and higher prevalence rates of family
AIDS in girls ([23], Table 1). Analyses investigating phys-
ical abuse adjusted for gender. Existing evidence suggests
a direct effect of family AIDS on physical and emotional
abuse victimisation and no direct effect of other chronic
illness [13]. Therefore, analyses were conducted separately
for children affected by AIDS and those affected by other-
illness. All mediational analyses adjusted for age, rural/
urban location, informal housing, province, receipt of pen-
sion, and made use of the temporal order within the data:
predictors and mediators were measured at baseline, out-
comes measured at follow-up.
Results
Children lost and retained at follow-up
Children lost to follow-up did not differ from those
retained with regard to gender (χ
2
= 0.07; p = 0.789) or
frequent physical abuse (χ
2
= 1.562; p=0.211). However,
children lost at follow-up were more likely to have expe-
rienced frequent emotional abuse (χ
2
= 6.624; p=0.010),
were older (t= 6.44; p= 0.011), and lived in poorer
households (t= 21.55; p<0.001) than those retained. It
is therefore possible that more vulnerable children were
lost to follow-up and findings should be interpreted with
this in mind.
Socio-demographic statistics for the population sample
are summarized in Table 2. The sample included 1095
participants from AIDS-ill households (31.2%) and 482
participants from households with other chronic illness
(13.7%) at baseline. Girls had higher rates of emotional
abuse (χ
2
= 8.591; p=0.003) and living in an AIDS-ill
household (χ
2
= 11.061; p=0.004) (Table 1). Households
affected by AIDS were experiencing higher levels of pov-
erty and disability compared to those with other chronic
illnesses and healthy households. Households affected by
AIDS had significantly higher prevalence rates for physical
and emotional abuse compared to healthy households.
Those affected by other chronic illness had lower preva-
lence rates of abuse than healthy households (Table 3).
Prevalence rates in this study were 16.6% for frequent
physical and 20.7% for frequent emotional abuse victim-
isation. The relationship between the interviewed child
and the ill person within the household was as follows:
40.2% were mothers, 24.2% grandparents, 11.9% fathers,
8% siblings, 3.2% the respondent themselves, 11.7%
Table 1 Gender differences in the variables used for
analysis
Boys (n = 1475) Girls (n = 1926)
Rural area at baseline 42.4% (712) 57.6% (969)
Mpumalanga province at baseline 45.3% (746) 54.7% (902)*
Informal housing at baseline 41.6% (444) 58.4% (624)*
Mean age at baseline 13.41 (SD 2.10)
SE .055
13.44 (SD 2.18)
SE .050
Poverty at baseline 2.61 (SD 2.30)
SE .060
2.74 (SD 2.33)
SE .053
Household receipt of pension
at baseline
13.2% (194) 13.0% (251)
Frequent physical abuse at
follow-up
44.5% (251) 55.5% (313)
Frequent emotional abuse at
follow-up
38.5% (271) 61.5% (433)**
Frequent physical abuse at baseline 17.0% (251) 19.1% (368)
Frequent emotional abuse at
baseline
17.4% (257) 20.6% (397)*
AIDS-illness at baseline 39.2% (417) 60.8% (646)***
Other chronic illness at baseline 46.3% (219) 53.7% (254)
Extent of ill person’s disability
at baseline
1.97 (SD 3.87)
SE .101
2.14 (SD 3.80)
SE .087
Chi
2
and two-sample t-tests Note: *p< .05, **p< .01, ***p< .001.
Meinck et al. BMC Public Health (2015) 15:444 Page 5 of 13

other family members, 0.4% non-relatives and 0.3% fos-
ter parents.
Mediation analysis
Mediational analyses were conducted for both household
AIDS-illness and household other chronic illness in line
with Hayes [46] to establish the extent of mediation. Six
separate models tested the direct and indirect effects of
household AIDS-illness and other chronic illness at
baseline on child abuse at follow-up through poverty
and the extent of the ill person’s disability at baseline.
Models were run separately for boys and girls for emo-
tional abuse. All analyses controlled for age, rural loca-
tion, informal housing, receipt of pension and province.
Frequent physical abuse victimisation
A positive direct effect of household AIDS-illness on fre-
quent physical abuse victimisation was observed (B=0.276,
95% CI 0.060 −0.493). Additionally, a positive indirect ef-
fect of household AIDS-illness on frequent physical abuse
through poverty (B=0.046, 95% CI 0.019 −0.083) and dis-
ability (B=0.112, 95% CI 0.014 −0.205) was obtained
(Figure 2).
A negative direct effect of other chronic illness on
frequent physical abuse victimisation was observed
(B=-0.294, 95% CI -0.581 −-0.007) was observed. Add-
itionally, a negative and positive indirect effect of house-
hold other chronic illness on frequent physical abuse
victimisation through poverty (B=-0.027, 95% CI -0.057 −
-0.011) and disability (B=0.029, 95% CI 0.012 −0.056)
were obtained respectively (Figure 3).
Frequent emotional abuse victimisation
For boys (Figure 4), a positive direct effect of household
AIDS-illness on frequent emotional abuse victimisation
was observed (B=0.409, 95% CI 0.089 −0.730). Addition-
ally, a negative indirect effect of household AIDS-illness
on frequent emotional abuse through poverty was ob-
tained (B=0.091, 95% CI 0.042 −0.162). Disability did not
affect the relationship between AIDS-illness and frequent
emotional abuse.
There was no direct effect of other chronic illness on
frequent emotional abuse. However, a negative and posi-
tive indirect effect of other chronic illness on frequent
emotional abuse through poverty (B=-0.056, 95% CI
-0.116 −-0.016) and disability (B=0.025, 95% CI 0.001
−0.064) respectively was observed (Figure 5).
For girls (Figure 6), a positive indirect effect between
household AIDS-illness and frequent emotional abuse
victimisation through poverty (B=0.055, 95% CI 0.024 −
0.102) was observed. Disability did not affect the rela-
tionship between AIDS-illness and frequent emotional
abuse.
There was no direct effect of other chronic illness on
frequent emotional abuse. However, a negative indirect ef-
fect of other chronic illness and frequent emotional abuse
through poverty (B=-0.032, 95% CI -0.068 −-0.007) was
observed (Figure 7).
Discussion
This is the first large-scale longitudinal study examining
the pathways from household chronic illness to child
abuse in the developing world through multiple medi-
ation analysis. AIDS-affected households, showed higher
levels of physical and emotional abuse compared to
healthy households while households affected by other
chronic illness had lower abuse prevalence rates.
Table 2 Characteristics of the sample at baseline and
follow-up
Baseline (n = 3515) Follow-up (n = 3401)
Gender (female) 56.7% (1992) 56.6% (1926)
Rural area 49.4% (1737) 49.4% (1681)
Mpumalanga Province 47.3% (1664) 49.8% (1681)
Informal housing 31.8% (1117) 20.6% (701)
Mean age 13.45 years (SD 2.15)
SE .036
14.67 years (SD 2.22)
SE .038
Poverty 2.71 (SD 2.32)
SE .040
2.75 (SD 2.34)
SE .040
Household receipt
of pension
13.1% (459) 9.2% (314)
Frequent physical abuse 18.3% (645) 16.6% (564)
Frequent emotional abuse 19.5% (687) 20.7% (704)
AIDS-illness 31.2% (1095) 17.7% (602)
Other chronic illness 13.7% (482) 12.5% (424)
Extent of ill person’s
disability
2.08 (SD 3.87)
SE .065
1.18 (SD 3.08)
SE .053
Table 3 Baseline characteristics of the outcome and mediator variables split by household illness status
Healthy (comparison group) (n = 1824) Other chronic illness (n = 482) AIDS-ill (n = 1095)
Physical abuse at follow-up 14.9% (278) 11.3% (64)* 20.9% (222)*
Emotional abuse at follow-up 18.7% (349) 19.9% (94) 24.6% (261)*
Poverty at baseline 2.58 (SD 2.29) SE .05 2.06 (SD 2.02) SE .93* 3.14 (SD 2.39) SE .07*
Disability at baseline .36 (SD 1.76) SE .04 2.81 (SD 3.87) SE .18* 4.74 (SD 4.73) SE .15*
Chi
2
and One-Way-Anova tests. Note: *p< .05.
Meinck et al. BMC Public Health (2015) 15:444 Page 6 of 13

There are no research findings to date that explain the
difference in abuse risk between families affected by
AIDS and those affected by other chronic illness. It is
possible that families affected by AIDS experience add-
itional and different stress factors to families affected by
other chronic illness. These could be fear of death and
severe symptomology [59], AIDS-related stigma [60] and
lower quality of life [61]. Furthermore, families affected
by chronic illness in this study suffered from diseases
with more straightforward treatment options and lower
perceived stigma such as diabetes or high blood pres-
sure. Existing studies investigating parenting in families
with chronic illness either focused on AIDS-affected or
cancer-affected families [19,21], both illnesses with high
levels of stigma and perceived shorter life expectancy.
Results from previous studies might therefore be more
applicable to AIDS-affected families than to those af-
fected by other chronic illness. Future research could
valuably explore linkages and differences between these
factors.
Direct and indirect effects of household chronic illness
on physical and emotional abuse victimisation were
found. In particular, direct and indirect effects were ob-
served for household AIDS-illness showing increased
AIDS-illness Frequent
physical abuse
Disability
Poverty
Indirect Effect:
.046* CI 95% (.019 to .083)
.641* CI 95%
(.491 to .791)
r2= .210
3.790* CI 95%
(3.548 to 4.033)
r2= .250
.071* CI 95%
(.027 to .116)
.030* CI 95%
.004 to .055)
Direct effect:
.276* CI 95% (.060 to .493)
Indirect Effect:
.112* CI 95% (.014 to .205)
-2LL = 2989.48
*si
g
nificant at
p
<.05
Figure 2 Direct and indirect effects of AIDS-illness on frequent physical abuse.
other-illness Frequent
physical abuse
Disability
Poverty
Indirect Effect:
-.027* CI 95% (-.057 to -.011)
-.368* CI 95%
(-.573 to -.163)
r2= .197
.637* CI 95%
(.267 to 1.008)
r2= .045
.074* CI 95%
(.029 to .118)
.046* CI 95%
(.023 to .068)
Direct effect:
-.294* CI 95% (-.581 to -.007)
Indirect Effect:
.029* CI 95% (.012 to .056)
-2LL = 2991.44
*si
g
nificant at
p
<.05
Figure 3 Direct and indirect effects of household other-illness on physical abuse.
Meinck et al. BMC Public Health (2015) 15:444 Page 7 of 13

risk for abuse victimization for children in AIDS-ill fam-
ilies through poverty and disability. Direct and indirect
effects were also found for households with other
chronic illness, surprisingly, showing reduced risk of
abuse and poverty for children in other ill households.
However, an increased risk for severe disability taht in-
creased risk for child abuse victimisation was also ob-
served. The findings of this study therefore extend
previous research from South Africa which found direct
associations between physical and emotional abuse vic-
timisation and household AIDS-illness but not with
other chronic illnesses [13,23] and the findings partially
correspond with this.
As hypothesised, disability was an important mediator
of the relationship between household AIDS-illness and
physical abuse, but surprisingly not emotional abuse.
Furthermore disability mediated the relationship be-
tween other-chronic illness and physical abuse for the
whole sample and emotional abuse for boys only. The
role of disability as a mediator is consistent with re-
search linking poor caregiver health to higher risk of
abuse [21].
AIDS-illness Frequent
emotional abuse
Disability
Poverty
Indirect Effect:
.091* CI 95% (.042 to .162)
.131* CI 95%
(.066 to 1.97)
.018 CI 95%
(-.019 to .055)
Direct effect:
.409* CI 95% (.089 to .730)
Indirect Effect:
.070 CI 95% (-.081 to .203)
.690* CI 95%
(.460 to .920)
r2= .234
3.867* CI 95%
(3.487 to 4.247)
r2= .262
-2LL = 1364.81
*si
g
nificant at
p
<.05
Figure 4 Direct and indirect effect of household AIDS-illness on frequent emotional abuse in boys.
other-illness Frequent
emotional abuse
Disability
Poverty
Indirect Effect:
-.056* CI 95% (-.116 to -.016)
.138* CI 95%
(.073 to .203)
.040* CI 95%
(.009 to .072)
Direct effect:
-.077 CI 95% (-.472 to .317)
Indirect Effect:
.025* CI 95% (.001 to .064)
-.403* CI 95%
(-.701 to -.104)
r2= .220
.614* CI 95%
(.063 to 1.164)
r2= .065
-2LL = 1370.82
*si
g
nificant at
p
<.05
Figure 5 Direct and indirect effects of household other-illness on frequent emotional abuse in boys.
Meinck et al. BMC Public Health (2015) 15:444 Page 8 of 13

Poverty was also an important mediator of the rela-
tionship between AIDS-illness and physical and emo-
tional abuse. Unexpectedly, lower levels of poverty were
a protective mediator of the relationship between other
chronic illness and physical and emotional abuse. This
study therefore corroborates current evidence that found
that households affected by other chronic illness in
South Africa appear to have a lower risk for poverty
compared to healthy and AIDS-affected ones [62]. The
lower risk for poverty in households affected by other
chronic illness in this current study decreased the risk
for child abuse victimisation in the mediation models.
However, poverty as a factor itself remained clearly
linked to an increased risk of child abuse.
Differences in poverty risk between households af-
fected by AIDS and other chronic illness could be attrib-
uted to differences in the age groups between the ill
household members. Chronic illnesses measured (i.e.
high blood pressure, diabetes) may be more likely to ap-
pear in older age people who are entitled to a state pen-
sion in South Africa [63]. Of the children in households
with chronic illness in this study, 26.6% reported being
cared for by their grandparents compared to 13.8% in
AIDS-affected households. State pensions have been
AIDS-illness Frequent
emotional abuse
Disability
Poverty
Indirect Effect:
.055* CI 95% (.024 to .102)
.600* CI 95%
(.402 to .799)
r2= .195
.092 * CI 95%
(.041 to .143)
.017 CI 95%
(-.014 to .048)
Direct effect:
-.019 CI 95% (-.240 to .278)
Indirect Effect:
.066 CI 95% (-.054 to .177)
3.727* CI 95%
(3.413 to 4.042)
r2= .243
-2LL = 2031.00
*si
g
nificant at
p
<.05
Figure 6 Direct and indirect effect of household AIDS-illness on frequent emotional abuse in girls.
other-illness Frequent
emotional abuse
Disability
Poverty
Indirect Effect:
-.032* CI 95% (-.068 to -.007)
-.343* CI 95%
(-.626 to -.061)
r2= .183
.093* CI 95%
(.042 to .144)
.019 CI 95%
(-.009 to .046)
Direct effect:
.038 CI 95% (-.286 to .362)
Indirect Effect:
.012 CI 95% (-.003 to .045)
.8645* CI 95%
(.143 to 1.146)
r2= .031
-2LL = 2030.97
*si
g
nificant at
p
<.05
Figure 7 Direct and indirect effect of household other-illness on frequent emotional abuse in girls.
Meinck et al. BMC Public Health (2015) 15:444 Page 9 of 13

shown to reduce household poverty as they are spread
across all members of a household [64,65].
The role of poverty is consistent with research linking
AIDS-affected households with high levels of deprivation
[66] as AIDS-illness increases household poverty [67]
through inability to work, medical expenses and exces-
sive funeral costs in case of AIDS-death [68]. On the
other hand, poorer households are at higher risk for
HIV infection and this can set up a vicious cycle [69].
Considerable differences were found in the pathways
to abuse depending on the abuse outcome, the child’s
gender and the illness status of the family. Differences in
maltreatment according to the child’s gender and to
family illness were expected due to previous studies sug-
gesting differences in risk between these groups [13,70].
However, no previous research has investigated pathways
from illness to abuse in a similar fashion before, and
speculation about these differences in results would go
beyond the scope of the data. Thorough future research
is needed to corroborate these findings and examine
possible reasons for these differences. If these persist in
future studies, there may be implications for policy
makers and practitioners in focussing interventions.
Limitations and future research
This study had a number of limitations. First, less than
two-thirds of the South African population know their
HIV status, which makes self-reporting of HIV status un-
reliable [71]. This study was therefore not able to iden-
tify households with HIV+, but asymptomatic members.
However, the verbal autopsy to identify AIDS-illness has
been successfully used in previous studies with good reli-
ability [15,23]. Furthermore, identifying only households
with AIDS sequelae allows for a fuller understanding of
this subgroup of individuals. Second, no scales for child
abuse victimisation have been validated for use in South
Africa. However, all scales were successfully used in prior
studies and showed good reliability in this sample [13,23].
Third, the study was carried out in randomly sampled
areas with 30%+ HIV prevalence. Results are therefore
not generalisable across the South African child popula-
tion but give a good indication of risks for children in
low-income areas with high HIV prevalence. Fourth, this
study measured the risk of abuse in families affected by
chronic illness, however, it should be noted that the ill
person and the person abusing the child may not be one
and the same. However, the results clearly indicate that
household illness increases the risk for child abuse vic-
timisation through poverty and extent of disability.
Fifth, referrals to child protective services at baseline
could have potentially influenced the results and levels
of abuse at follow-up. Unfortunately, social services in
South Africa are overburdened and understaffed and
rarely able to respond to referrals in a timely manner
[72]. Only a tiny number of children referred at baseline
(<3%) had been contacted by the appropriate services by
follow-up and impact of baseline referrals on results is
therefore unlikely. Sixth, the study measured child abuse
committed by an adult within the child’s network but
investigated mediation between household factors. The
perpetrator could, therefore be an adult outside the
child’s home i.e. a teacher. In this study, 74.6% of all
physically and emotionally abusive acts were carried out
within the child’s home, with parents and relatives as the
perpetrators [73], suggesting that the observed effects on
physical and emotional abuse are primarily associated
with events occurring within the household.
Seventh, the data presented cannot determine causality
and this study was therefore not able to determine
whether living in a family affected by chronic illness
causes an increased risk for child abuse victimisation.
Longitudinal observational designs allow for controlling
of baseline confounders and identification of correlate
directionality because the hypothesised risk factors pre-
cede the outcome [34]. They are therefore superior to
cross-sectional studies where temporality cannot be de-
termined. This study established that baseline chronic
illness has an effect on risk for child abuse victimisation
at follow-up. Temporal order could not be established
for the mediation analyses as these were only cross-
sectional due to only two time points collected. How-
ever, cross-sectional mediation analyses can be used for
theory generation and development, with the under-
standing that the hypothesis arising from these analyses
will then have to be verified in longitudinal data [74].
Eighth, there is a strong likelihood of unmeasured
confounding in this study as suggested by the low values
in R
2
. Even though models adjusted for potential con-
founding variables reported by children, caregiver related
confounders such as mental health or substance use
could not be accounted for. Due to the design of the
study, unmeasured confounding cannot be ruled out.
Finally, the study used child self-report with interviewer-
guided questionnaires. Opinions differ whether children
are reliable informants regarding disability and illness
within the household. However, previous research has
used the verbal autopsy and disability measures success-
fully [15] and has shown that children often carry out car-
ing tasks within the home that allow them to witness
physical ability and symptomology of ill household mem-
bers [75]. Furthermore, a recent study investigating inter-
rater reliability between adult-child dyads using the verbal
autopsy tool found concordant reporting of adult HIV sta-
tus to be 72% and no significant association between con-
cordance and child age [76].
Interviewer presence during surveying may have in-
creased the likelihood of under-reporting, in particular
of socially undesirable events such as child abuse.
Meinck et al. BMC Public Health (2015) 15:444 Page 10 of 13

Computer assisted interviewing may increase reporting
of stigmatized events or behaviours in some cases [77].
However, it may not be suitable for all settings, such as
the very rural ones in which parts of this study were
conducted and where participants may be intimidated by
the opportunity to use a computer to answer questions
[78,79]. The advantage of the system used in this study
is that it allowed for more detailed answers and a very
good interviewer-participant relationship, which facili-
tated follow-up. Future work is needed to examine other
potential factors, such as parental risk factors of mental
health and substance abuse [12,80,81] and predictors of
multiple abuse victimisation.
Conclusions
This is the first study to investigate pathways from
household illness to physical and emotional child abuse
via poverty and disability. There are currently an esti-
mated 85 million AIDS-affected children in sub-Saharan
Africa [82] and millions more in households affected by
chronic illness [83]. The present study highlights the dif-
ferences in risk for child maltreatment in families af-
fected by AIDS and those affected by other chronic
illness, with those affected by AIDS at higher risk for
physical and emotional abuse victimisation. Findings
showed that pathways to abuse operated differently and
even contradictory depending on family illness status.
They suggest the importance of recognising two groups
of children at heightened risk of child maltreatment:
AIDS-affected and those affected by other chronic illness
with high levels of disability. Services should include this
in assessments of child well-being. In particular, inter-
ventions that effectively lower household poverty levels
and support families with chronic illnesses may have
additional positive impacts on reducing risks of child
maltreatment, although further research is essential to
confirm these findings.
In South Africa, social grants have been found to be
effective in reducing household poverty and improving
child outcomes [84,85]. Another effective way to support
caregivers and reduce abuse are parenting interventions
[86], and while there is limited evidence for these from
South Africa and other low- and middle-income coun-
tries [87], a suite of parenting interventions for this pur-
pose and various age groups is currently being tested
[88]. In order to reduce the compound vulnerability of
children in households affected by chronic illness and to
address child abuse in South Africa, it is essential that
we rigorously test child abuse interventions and take
those that are effective to scale.
Endnote
a
For the purpose of this paper child abuse and child
maltreatment will be used interchangeably.
Additional files
Additional file 1: Original measurement items for child physical
and emotional abuse victimisation.
Additional file 2: Physical and emotional abuse at follow-up:
Individual response frequencies.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
LC and MB had responsibility for the overall study design and management.
FM had responsibility for conceptualizing and writing the paper. FM
conducted part of the fieldwork and data collection, and also led the
analyses. LC and MB contributed to the analyses. LC and MB helped FM with
the interpretation of the findings. All authors reviewed and approved the
final version.
Acknowledgments
The authors wish to thank the children who participated in the study, their
families, all the fieldworkers working tirelessly to interview as many children
as possible, the Rural AIDS Development Action Research programme
(RADAR) at the University of the Witwatersrand, Cape Town Child Welfare,
Dr. Thees Spreckelsen, Dr Jenny Doubt, Jennifer Rabedeau, Prof Lucy Bowes,
Prof Lorraine Radford, Prof Frances Gardner and Prof. Cathy Ward. This study
was funded by the Economic and Social Research Council (UK) and the
National Research Foundation (RES-062-23-2068), the National Department of
Social Development, the Claude Leon Foundation, the Nuffield Foundation
(OPD/31598), the Health Economics and HIV/AIDS Research Division at the
University of KwaZulu-Natal (R14304/AA002), and the John Fell Fund (103/
757), the Leverhulme Trust (UK, www.leverhulme.ac.uk) [grant number
PLP-2014-095], the University of Oxford’s ESRC Impact Acceleration Account
and the European Research Council under the European Union’s Seventh
Framework Programme (FP7/2007-2013, ERC grant agreement (313421). FM
was funded by an ESRC studentship (OSSID 454387).
Author details
1
Centre for Evidence-Based Intervention, Department of Social Policy &
Intervention, University of Oxford, Barnett House, 32 Wellington Square,
Oxford OX1 2ER, UK.
2
Department of Psychiatry and Mental Health, University
of Cape Town, Cape Town, South Africa.
3
Health Economics and HIV/AIDS
Research Division, University of KwaZulu-Natal, Durban, South Africa.
4
Health
Psychology and Behavioural Medicine Research Group, School of Psychology
and Speech Pathology, Curtin University, Perth, Australia.
Received: 27 May 2014 Accepted: 22 April 2015
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