Memory Book Interventions With Orphaned Children in South Africa, Kenya, and India: A Global Partnership

The Memory Book intervention program, a psychosocial support program for orphaned and vulnerable children (OVC) (King et al., 2009), was initially developed and implemented in South Africa in 2005 by a nurse leader with a supportive volunteer base in the United States. The books were implemented to facilitate orphaned children in "telling their story" of loss and grief and to foster their sense of well-being, personal identity, and resilience (Masten, 2001). The Memory Book utilizes drawings and a story-telling format to help children retell their story to real or imagined audiences to support the integration of their thoughts and feelings about their individual grief response. To date, approximately 27,000 Memory Bookshave been distributed in 15 countries worldwide with 1,600 books distributed in South Africa, 300 books in Kenya, and 950 books in India, creating a collaborative global partnership for a grief recovery program for at-risk children.

Background

Storytelling and drawing are primary methods implemented in the Memory Bookprogram intervention. This approach is similar to photo voice methods and supports the oral cultural storytelling traditions for these countries (Fournier et al., 2014). These drawing, writing, and talking methods offer a visual participatory method that complements the African counseling method for children with limited literacy skills.

The cultural context and circumstances leading to an orphaned state for OVCs in South Africa, Kenya and India is entwined with the HIV/AIDS pandemic with abandonment due to poverty, disease or war. As the HIV/AIDS pandemic is currently in its third decade, South Africa continues to have the highest prevalence rates with 18% of persons living with HIV/AIDS. Kenya's rates rank fourth globally (5% of persons living with HIV/AIDS) while India ranks third with 6% of persons living with AIDS (UNAIDS, Gap Report, 2013). In addition to the impact of HIV/AIDS, South Africa has experienced challenges with the development of the infrastructure to support economic, health care, and educational resources in the post-apartheid era (Sheehan et al., 2015). Kenya has experienced a chaotic environment threatening the survival of its children as a result of war, while India's devastating poverty and illiteracy has been further intensified by the impact of the stigmatization of HIV/AIDS (Kumar, 2012). Traditional models for surrogate parenting by extended families have been strained by the frequent loss of one or both parents of affected children resulting in the need for alternative care models such as orphanages. Orphaned children have sustained many threats to their holistic health, including the loss of precious family memories, severed family relationships, stigmatization, and potential significant paralysis in development due to loss and grief (Wood, Theron, & Mayaba, 2012; Kumar, 2012).

Literature Review

Childhood traumatic or complicated grief (CTG) is a condition in which trauma symptoms as a result of grief, interrupt children's ability to navigate the usual grieving process (Crenshaw, 2005). Multiple studies have confirmed the increased mental health risks among OVCs due to HIV/AIDS (Cheney, 2015; Cluver, 2012; Crenshaw, 2005;Morantz & Heymann, 2010; & Thupayagale-Tshweneagae, 2012). A burden of silence threatens the impact of grief world-wide, but African children are often socially conditioned to hide and internalize their feelings enhancing the risk for pathological grief leading to withdrawal, isolation, and depression (Thupayagale-Tshweneagae, 2012). The resulting emotional suffering threatens children into adolescence and adulthood (Cheney, 2015) with potential developmental paralysis unless they are compassionately accompanied in their grief journey (Schuurman, 2003). Preservation of memories, a key component of the grief journey, offers the potential for greater insight, truthful perspectives, resilience, and even positive growth as a child matures (Scaletti & Hocking, 2010; Schuurman, 2003; Tedeschi & Calhoun).

Research on the cultural role of resilience has advanced in the past several decades (Masten, 2014); impacting how research with HIV-affected children is shifting from an emphasis on vulnerability and risks toward greater support for coping strategies through promotion of protective factors that enhance pathways to psychosocial health (Fournier et al., 2014; Skovdal & Daniel, 2012). Unger et al. (2007) identified seven factors to enhance resilience in youths across cultures, and linked positive adjustment to facilitation by social ecologies (Unger, 2012). Two of these factors, access to supportive relationships and the development of identity and positive self-concept, were supported through the Memory Books program intervention findings. Masten and Wright (2010) highlighted the critical role of contextual social support through the encouragement of attachment relationship and guidance for self-regulation and the promotion of problem-solving skills that lead to resilience.

Methods

A qualitative phenomenological approach was implemented in a multi-site study to evaluate the Memory Book intervention in six children's homes in South Africa, Kenya and India. Following university institutional ethics review board approval in the United States, a convenience sample strategy was implemented. Separate focus group interviews with children (n = 65) and their caregivers (n = 6) were conducted at each children's home. Child participants ranged in age from 10 to 17 (n=41 for ages 10-13; n=25 for ages 14-17). Informed consent was obtained from administrators and caregivers of the children's homes and assent was secured with each of the child participants prior to interviews. Children were asked to share sections of their personal memory books in small groups of three to five children with encouragement to tell their story through an open-ended questioning process. Following data saturation with multiple focus groups at the identified international sites, data were analyzed based on a constant comparison method for narrative themes. Theme confirmation between the three researchers was maintained throughout the data analysis process and member checking was solicited at multiple study sites with OVCs' adult caregivers.

Results

Study findings offer evidence to support the ability of children to work through loss and grief when they are assisted in preserving and telling their story through the use of Memory Books. Common themes offered by orphans between the six sites as a result of the intervention included support for their identity, awareness of family and significant relationships, emotional expressions, coping and hope for the future. Primary themes for all three countries included both identity and relationships, illustrating how children prize and value achievement, a sense of worth and new relationships to fill the void of biological losses. Spirituality was emphasized as a highly valued source of coping support in all three countries. Emotional expression was also common to all countries despite the non-expressive cultural norms.

Implications

Memory Books supported the children's ability to focus on higher levels of their basic needs including love, belonging and self-identity. The books offered children a respite from their focus on survival with an opportunity for reflection. The interventions offered through Memory Books presented an opportunity for children to embrace and record coping strategies demonstrating how children prized dreams for their future as a means of coping and hope.

Memory Books programs assisted children to chronicle their lives through the processing of their hidden and silent emotions through storytelling and drawing. This intervention program offers an inexpensive, accessible and protective resource to enhance resilience for these children (Scaletti & Hocking, 2010; Wood et al., 2007). Memory Books poses options for sustained future interventions for orphaned children by nurses, care providers, and other healthcare providers through collaborative global partnerships with children's homes and other settings.