Poorer health and nutritional outcomes in orphans and vulnerable young children not explained by greater exposure to extreme poverty in Zimbabwe


Corresponding Author Helen Watts, Department of Infectious Disease Epidemiology, Imperial College London, St Mary's Campus, London, W2 1PG, UK. Tel.: (+44) 0207 5943640; Fax: (+44) 0207 5943282; E-mail: h.watts@imperial.ac.uk


Objective  To describe patterns of association between different groups of young orphans and vulnerable children (OVC) and their nutritional and health outcomes; and to develop a theoretical framework to analyse the determinants of child malnutrition and ill-health, and identify the different mechanisms which contribute to these outcomes in such children.

Methods  We developed and tested a theoretical framework to explain why orphans and vulnerable children experience more ill-health and malnutrition based on statistical analysis of data on 31 672 children aged 0–17 years (6753 aged under 5 years) selected from the Zimbabwe OVC Baseline Survey 2004.

Results  28% of children aged 0–4 years at last birthday were either orphans or vulnerable children. They were more likely than non-vulnerable children to have suffered recently from diarrhoeal illness (age- and sex–adjusted odds ratio, AOR, 1.27; 95% CI 1.09–1.48) and acute respiratory infection (1.27; 1.01–1.59) and to be stunted (1.24; 1.09–1.41) and underweight (1.18; 1.02–1.36). After further adjustment for exposure to extreme poverty, OVC remained at greater risk of diarrhoeal disease (AOR 1.25; 1.07–1.46) and chronic malnutrition (1.21; 1.07–1.38). In 0–17-year-olds, OVC with acute respiratory infection were more likely not to have received any treatment even after adjusting for poverty (AOR 1.29; 95% CI 1.16–1.43).

Conclusion  Differences in exposure to extreme poverty among young children by OVC status were relatively small and did not explain the greater malnutrition and ill-health seen in OVC.


Objectif  Décrire les profiles des associations entre différentes sortes d'orphelins et jeunes enfants vulnérables (OEV) et les résultats de leur état nutritionnel et de santé; développer un cadre théorique pour analyser les déterminants de la malnutrition et des maladies infantiles; et identifier les différents mécanismes qui contribuent à ces résultats chez les OEV.

Methodes  Développement et test d'un cadre théorique pour expliquer les mécanismes par lesquels l'expérience vécue par les OEV résulte en un accroissement la de malnutrition et des maladies infantiles sur base de l'analyse statistique de données collectées chez 31672 enfants âgés de 0 à 17 ans (comprenant 6753 enfants de moins de 5 ans) choisis dans une enquête de ligne de base sur les OEV en 2004 au Zimbabwe.

Resultats  28% des enfants âgés 0 à 4 ans à leur récent anniversaire étaient soit des orphelins ou des enfants vulnérables. Les OEV étaient plus susceptibles que les enfants non vulnérables d'avoir souffert récemment de maladie diarrhéique (rapport de cotes corrigés pour le sexe et l’âge, AOR = 1,27; IC95%: 1,09–1,48), d'infection respiratoire aiguë (AOR = 1,27; IC95%: 1,01–1,59), de croissance altérée (1,24; IC95%: 1,09–1,41) et de poids insuffisant (AOR = 1,18; IC95%: 1,02–1,36). Après un ajustement supplémentaire pour l'exposition à l'extrême pauvreté, les OEV restaient à un risque plus élevé pour la maladie diarrhéique (AOR = 1,25; IC95%: 1,07–1,46) et la malnutrition chronique (AOR = 1,21; IC95%: 1,07–1,38). Chez les enfants de 0 à 17 ans, les OVC avec une infection respiratoire aiguëétaient plus susceptible de n'avoir reçu aucun traitement même après ajustement pour la pauvreté (AOR = 1,29; IC95%: 1,16–1,43).

Conclusion  Les différences dans l'exposition à l'extrême pauvreté chez les jeunes enfants selon le statut OEV étaient relativement faibles et n'expliquaient pas la malnutrition et des maladies plus importantes chez les OEV.


Objetivo  Describir los patrones de asociación existentes entre huérfanos jóvenes y niños vulnerables (HNV) y sus resultados nutricionales y de salud; así como desarrollar un marco teórico para analizar los determinantes de la malnutrición y la mala salud infantil e identificar los diferentes mecanismos que contribuyen a estos resultados en HNV

Métodos  Desarrollo y puesta a prueba de un marco teórico para explicar los mecanismos a través de los cuales los HNV experimentan resultados de un aumento en mala salud infantil y malnutrición, mediante un análisis estadístico de 31 672 niños con edades comprendidas entre los 0–17 años (6753 menores de 5 años) seleccionados del estudio de base de HNV del 2004 en Zimbabwe.

Resultados  Un veintiocho por ciento de los niños con edades comprendidas entre los 0–4 años, eran o bien huérfanos o niños vulnerables al momento de su último cumpleaños. Los HNV tenían más probabilidad que los no vulnerables de haber sufrido recientemente de diarrea (razón de posibilidades ajustada por edad y sexo, RPA, 1.27; 95% CI 1.09–1.48) o una enfermedad respiratoria aguda (1.27; 1.01–1.59), de tener raquitismo (1.24; 1.09–1.41) o bajo peso (1.18; 1.02–1.36). Después de un ajuste por exposición a la pobreza extrema, los HNV continuaban teniendo un mayor riesgo de enfermedad diarreica (RPA 1.25; 1.07–1.46) y malnutrición crónica (1.21; 1.07–1.38). En niños de 0–17 años, los HNV con infección respiratoria aguda tenían más probabilidad de no haber recibido tratamiento, incluso después de haber ajustado para pobreza (RPA 1.29; 95% CI 1.16–1.43).

Conclusión  Las diferencias en exposición a la pobreza extrema entre niños pequeños con estatus HVN era relativamente pequeñas y no explicaban el mayor grado de malnutrición y mala salud visto en los HVN.


In Zimbabwe, more than 23% of children were orphans in 2003; this is one of the highest rates in sub-Saharan Africa UNICEF (2005). The HIV/AIDS epidemic is the main cause of this orphan crisis. Even if the incidence of HIV is brought under control, the number of orphans will continue to increase for some years because of the long incubation period of the disease (Gregson et al. 1994; Whiteside et al. 2003). Orphans and vulnerable children (OVC) are potentially at greater risk of poor health and nutrition because they are more likely to be extremely poor, may receive less care and may themselves be HIV-infected via parent-to-child transmission.

One of the main causes of early child morbidity and mortality in developing countries is malnutrition (Pelletier et al. 1995; Muller et al. 2003; Sarker et al. 2005). The effects of poverty and hunger are intertwined and undoubtedly impinge on child survival, but the dynamics of interaction are poorly understood (Atinmo & Oyediran 2005). Many OVC suffer from cycles of poverty as a result of the illness and death of their parents Matshalaga and Powell (2002). The picture emerging is that OVC are especially vulnerable and are at increased risk of malnutrition and ill-health (Ayieko 1997; Sarker et al. 2005). However, the evidence for the effect of orphanhood and child vulnerability on child nutrition is weak and variable (Nalwanga-Seboina & Sengendo 1987; Panpanich et al. 1999; Lindblade et al. 2003; Sarker et al. 2005).

Our aims were to describe patterns of association between different forms of OVC experience and nutritional and health outcomes in Zimbabwe, and to develop a theoretical framework to analyse the determinants of child malnutrition and ill-health, and to identify the different mechanisms which contribute to these outcomes in OVC.



In 2004, UNICEF Zimbabwe and the Government of Zimbabwe conducted a cross-sectional survey to improve understanding of the situation of OVC in the country. The survey was conducted in 21 districts: 19 in rural areas and 2 in urban Harare and Bulawayo. The original sample size was calculated assuming that 17 districts would be included, but four more districts were added later. The 17 original districts were districts where UNICEF planned to implement programmes with the Government of Zimbabwe (GOZ). The four additional districts were covered under the areas where the Education Transition and Recovery Project (ETRP) is operating.

UNICEF used enumeration areas (EAs) created by the cartographic section in the Census Office of the Central Statistics Office (CSO) to sample households. The complete list of all EAs (1 EA contains approximately 100 households) in each of the convergence districts was used as a sampling frame for selection of sites in each district. The frame was sorted according to geocode (a unique code consisting of 10 digits) and number of households in the EAs. For each district, a sample of eight EAs was randomly selected using a probability-proportional-to-size (PPS) approach. Using district maps, the eight selected EAs were located and, from these, five were selected purposively so as to provide geographical coverage of the entire district. The three EAs not so selected were moved to the substitute list and would be used if circumstances (security, political or other) determine that it will not be possible to visit one or more of the selected EAs. The UNICEF survey team then located selected EAs and once there, visited and interviewed every household in the EA. UNICEF team leaders were instructed to continue locating EAs and interviewing every household in each EA, until at least 350 OVC and 500 households were covered (UNICEF, 2005–2006). Non-OVC were also interviewed in each household in the selected EAs. Further details of the methods used in this survey can be found in the survey report (UNICEF & Go Z 2004/2005). The sample size (12 356 households) was determined based on draft guidelines developed by UNICEF/UNAIDS on sampling OVC UNICEF (2003).

The working definition of an OVC used for measurement purposes in the UNICEF survey was a child under 18 years of age, who is either:

  • An orphan (a child who has lost either one or both of his/her parents); or
  • Lives in a household where at least one adult died in the previous 12 months; or
  • Lives in a household where at least one adult was seriously ill for at least 3 months in the previous 12 months; or
  • Lives in a child-headed household (i.e. where the head of household is less than 18 years of age).

The survey data used in this analysis includes information on children's OVC status, anthropometric measurements, common infections and socio-economic factors. 31 672 children aged 0–17 years, of whom 5150 were aged 6–59 months, were selected from the survey, based on the criterion that complete malnutrition and illness data were available for each individual. Data were incomplete for 1954 children; there was no statistical association between children with missing data and the outcome variables used in this analysis.

The two main indicators used to assess the health status of the children were reportedly acute respiratory illness (ARI) and diarrhoeal illness, both in the past 2 weeks. Three growth assessment indicators — stunting (height-for-age; <−2 z-scores), wasting (weight-for-height; <−2 z-scores) and underweight (weight-for-age; <−2 z-scores) — were used to assess the nutritional status of children 6–59 months. Computer software, EpiInfo version 3.3, was used to compute the malnutrition indicators and to make comparisons with reference standards. The reference population used the National Center for Health Statistics data that was revised by the CDC in 2000 (Kuczmarski et al. 2000).

Theoretical framework

A hierarchical framework was developed from the literature (Figure 1) to explain the mechanisms through which orphanhood might lead to increased malnutrition and ill-health during childhood. In summary, the framework hypothesises that OVC experience can result in residence in poorer households – due, for example, to the death of a family breadwinner – and/or stigma and discrimination. Each of these may lead to poorer childcare, which can be manifested in poorer diet, unmet basic needs – such as shelter, clothing and school education – and inadequate healthcare. These, in turn, can result in insufficient energy intake and untreated infections, leading to a downward spiral of malnutrition, weakened immune system and ill-health. In the case of young maternal and double orphans, and babies with seriously ill mothers, lack of breast-feeding can exacerbate these problems. Differences in exposure to perinatal HIV infection may also contribute to this.

Figure 1.

 Hierarchical framework for investigating the causal pathways between OVC experience and ill-health and malnutrition. NB/ The UNICEF indicators used in the analysis are shown in the brackets - where there is no appropriate indicator to fit into the framework, ‘NA’ (not available) is noted under the risk factor.

Indicators based on questions asked in the survey were developed to test the mechanisms contributing to heightened malnutrition and ill-health posited in the theoretical framework. The indicators comprised: UNICEF's wealth index (UNICEF & Go Z 2004/2005); children not breast-fed (0–11 months only); no child health card; incomplete vaccinations (including BCG, diphtheria, polio and measles); ARI not treated outside the home (this variable is used as an indication of child discrimination by comparing the treatment-seeking behaviour of the guardian of an orphan and non-orphan child suffering from ARI. Any treatment sought outside of the home was considered, regardless of the appropriateness of the source of treatment.).

Data analysis: pattern of association between OVC experience, malnutrition and ill-health

The prevalence of malnutrition was assessed by calculating the percentages of children 6–59 months who were reported to be stunted, wasted or underweight (<−2 z-scores). The percentages of children aged 0–17 years and under 5 years who had suffered from an ARI or diarrhoeal illness in the previous 2 weeks were taken to be indicators of the prevalence of ill-health. Adjusted odds ratios (AORs) for experiences of malnutrition and ill-health in OVC compared with non-OVC were calculated using logistic regression controlling for differences in the age and sex of OVC and non-OVC.

Causal pathways leading from OVC experience to malnutrition and ill-health

Initially, the intermediate determinants of nutritional and health problems posited in the hierarchical framework were evaluated in non-OVC. This was done to enable the determinants to be identified without any problems of confounding with OVC status. For each outcome variable, logistic regression analysis initially controlled only for sex and age to establish whether each of the possible determinants had a statistically significant effect. Reverse step-wise multiple regression analysis was then conducted to establish the degree to which each determinant, when combined with the others, contributed to predicting the outcome variable. Variables with a P-value > 0.1 were removed from the model. Once the determinants showing significant independent effects had been identified, final models were developed in which OVC were included, to test whether the determinants identified accounted for the differences in nutrition and health outcomes or whether OVC status remained a significant factor. All analyses were done in stata 8.0.


More than a quarter (28%) of children under the age of 5 years living in the study areas were found to be either an orphan or a vulnerable child. Approximately 10% (n = 515) of children were paternal orphans, 2% (n = 103) maternal orphans, 2% (n = 83) double orphans and 15% (n = 796) were vulnerable because of other reasons.

Prevalence of ill-health

Seven per cent of children under the age of 5 years had suffered from an ARI in the 2 weeks prior to interview. There was no difference in the percentage of children suffering from an ARI by sex or between rural and urban areas (UNICEF & Go Z 2004/2005). Eighteen per cent of under-5-year-olds were reported to have suffered from diarrhoeal illness in the past 2 weeks, with children under the age of 2 years being the most likely to experience diarrhoea (28%).

OVC were significantly more likely than non-OVC to suffer from a diarrhoeal disease (sex- and age-adjusted AOR 1.27, 95% CI 1.09, 1.48) and from an ARI (AOR 1.27, 95% CI 1.01, 1.59). Nineteen per cent of OVC compared with 17% of non-OVC were reported to have recently suffered from a diarrhoeal disease. Seven per cent of OVC compared with 6% of non-OVC were reported to have recently suffered from an ARI.

In both groups, diarrhoeal illness was most common in the first 2 years of life and became less frequent as children grew older. When the data were disaggregated by way of OVC experience, vulnerable children other than orphans were more likely than non-OVC to have suffered a recent episode of diarrhoea or ARI (Figure 2). There were no significant differences between any of the categories of orphans and non-OVC.

Figure 2.

 Prevalence of diarrhoeal and ARI illness in children aged 0-4 years by single year of age.

Prevalence of malnutrition

Almost one-third (29%) of children aged 6–59 months were stunted (<−2 z-scores), 19% were underweight and 5% were wasted. Fewer children were found to be severely malnourished – 10% of those aged 6–59 months were severely stunted (<−3 z-scores), 3% severely underweight and 1% severely wasted. Prevalence of malnutrition increased until age 6–12 months and declined thereafter (Figure 3). The decline in prevalence between ages 12 and 59 months was less steep for stunting (AOR 0.96 per year, P = 0.2) and being underweight (AOR 0.85 per year, P < 0.001) than for wasting (AOR 0.63 per year, P < 0.001).

Figure 3.

 Prevalence of malnutrition in children aged 6-59 months by age and form of malnutrition.

With all male and female OVC aged 6–59 months grouped together, OVC were more likely to be stunted (AOR 1.24, 95% CI 1.09, 1.41) and to be underweight (AOR 1.18, 95% CI 1.02, 1.36) than non-OVC. Thirty-three per cent of OVC were found to be stunted compared with 28% of non-OVC. Twenty-one per cent of OVC were found to be underweight compared with 18% of non-OVC. There was no difference in wasting between the two groups. Double orphans were more likely than non-OVC to be underweight (AOR 1.84, P = 0.01) and showed non-significant trends towards increased stunting and wasting (Figure 4). Maternal orphans had heightened risks of stunting (AOR 1.70, P = 0.01) and of being underweight (AOR 1.83, P < 0.001). Paternal orphans were at heightened risk of being stunted (AOR 1.23, P = 0.04). Non-orphaned vulnerable children had similar risks of stunting, wasting and being underweight when compared with OVC.

Figure 4.

 Age-adjusted odds ratios for malnutrition (stunting, wasting and underweight) in children aged 6-59 months by sex and OVC status.

Determinants of ill-health and malnutrition

Table 1 shows the relative frequencies of the different hypothesised determinants of ill-health and malnutrition by OVC status in children aged 6–59 months. Paternal orphans were less likely than other children to sleep under a bednet, but the overall number of children who did have bednets was very small. Fewer maternal and double orphans compared with other children had child health cards.

Table 1.   Frequency of determinants of ill-health and malnutrition by OVC status
DeterminantDouble orphans Test for differencen (%)Maternal orphans Test for differencen (%)Paternal orphans Test for differencen (%)Other vulnerable children Test for differencen (%)Non-OVCs, n (%)
OR[95% CI]P-valueOR[95% CI]P-valueOR[95% CI]P-valueOR[95% CI]P-value
Socio-economic factors
 First quintile (wealth index)1.4[0.86, 2.30]0.2222 (27)0.7[0.43, 1.26]0.20 16 (16)1.2[0.94, 1,46]0.21119 (23)1.1[0.89, 1.30]0.42165 (21) 918 (21)
Poorer care – diet
 Not breastfeed (0–11 months only)   1 (100)    2 (100)    1 (5)    1 (100)  11 (2)
Poorer care – basic needs
 Did not sleep under bednet  83 (100)1.1[0.26, 4.44]0.92101 (98)3.6[1.17, 11.76]0.03512 (99)1.4[0.68, 2.31]0.33784 (98)4383 (98)
Poorer care – healthcare
 No child health card3.1[1.60, 5.39]<0.00113 (17)2.0[1.09, 3.73]0.02 12 (12)0.9[0.57,1.26]0.61 29 (6)0.8[0.52, 1.04]0.17 42 (5) 283 (6)
 Incomplete vaccination2.9[0.73, 11.88]  6 (67)0.6[0.15, 2.10]0.38  3 (27)1.4[0.91, 2.19]0.14 42 (49)1.1[0.71, 1.45]0.76 62 (42) 382 (40)
 ARI not treated outside home   0 (0)0.5[0.06, 4.17]0.48  1 (12)1.7[0.84, 3.72]0.18 12 (33)1.5[0.93, 1.69]0.22 20 (29)  67 (22)
Frequent infections
 Diarrhoea in past 2 weeks1[0.40, 1.37]0.9812 (14)1.0[0.48, 1,42]0.91 16 (16)1.1[0.72, 1.17]0.67 89 (17)1.4[1.13, 1.64]<0.001183 (23) 830 (19)
 ARI in past 2 weeks0.2[0.02, 1.22]0.10 1 (1)1.3[0.57, 2.48]0.52  8 (8)1.1[0.73, 1.50]0.61 36 (7)1.4[1.10, 1.930.01 73 (9) 301 (7)
 N   83   103   515   7964478

There was no difference in access to treatment in recent cases of ARI in the 0–4 age-group. There were few orphans and consequently few cases of ARI in this age-group in the reporting period (2 weeks). In the wider age-range 0–17 years, OVC with ARIs were significantly more likely not to have received treatment, compared with non-OVC (AOR 1.29 [95% CI, 1.16–1.43]; P < 0.001). However, the difference was only statistically significant in non-orphaned vulnerable children (AOR 1.38 [95% CI, 1.20–1.58]; P < 0.001). The association in all OVC remained significant (AOR 1.29 [95% CI, 1.16–1.43]; P < 0.001) after adjustment for poverty.

Patterns of statistical association between the hypothesised determinants and recent illness are shown for children aged 0–4 years in Table 2. As noted above, OVC aged 0–4 years were somewhat more likely than non-OVC to experience diarrhoeal disease and ARI. Extreme poverty, an incomplete vaccination record, frequent ARIs and malnutrition indicators – all show positive associations with increased risk of diarrhoeal disease in univariate analysis. In multivariate analysis, extreme poverty, frequent ARIs and being underweight show independent associations with diarrhoeal disease. Each of these variables still had an effect when OVC were included in the model. In contrast, no associations were found between ARI and poverty or vaccination history, but there were associations with diarrhoea and wasting which remained statistically significant in the multivariate analysis.

Table 2.   Determinants of diarrhoeal disease and ARI in children aged 0–4 years and contribution to association between OVC status and ill-health
DeterminantUnivariate (non-OVCs) Test for differencenMultivariate (non-OVCs)† Test for differenceMultivariate (including OVCs)
OR95% CIOR95% CIOR95% CI
  1. † Most parsimonious model (variables non-significant at the 90% level are dropped using reverse step-wise logistic regression)

Determinants of ill-health (diarrhoea)
 OVC1.27[1.09, 1.48]1,535 1.25[1.07, 1.46]
Socio-economic factors
 First quintile (wealth index)1.35[1.10, 1.65]7471.34[1.09, 1.64]1.37[1.16, 1.63]
Poorer care – basic needs
 Did not sleep under bednet1.53[0.93, 2.53]3,805  
Poorer care – healthcare
 No child health card0.97[0.69, 1.36]246  
 Incomplete vaccinations0.71[1.02, 1.92]339  
 ARI not treated outside home0.89[0.43, 1.81]49  
Frequent infections
 Diarrhoea in past 2 weeksN/A      
 ARI1.92[1.44, 2.56]2571.87[1.39, 2.50]1.88[1.48, 2.39]
 Stunting1.27[1.06, 1.53]1,079  
 Wasting1.55[1.12, 2.15]202  
 Underweight1.69[1.39, 2.07]7021.57[1.28, 1.93]1.52[1.28, 1.80]
Determinants of ill-health (ARI)
 OVC1.27[1.01, 1.59]1,535 1.23[0.98, 1.55]
Socio-economic factors
 First quintile (wealth index)1.16[0.85, 1.59]747  
Poorer care – basic needs
 Did not sleep under bednet1.52[0.55, 4.18]3,805  
Poorer care – healthcare
 No child health card0.88[0.51, 1.51]246  
 Incomplete vaccinations0.78[0.75, 2.17]339  
 ARI not treated outside homeN/A      
Frequent infections
 Diarrhoea in past 2 weeks2.07[1.56, 2.74]6901.87[1.40, 2.50]1.89[1.49, 2.40]
 Stunting1.02[0.77, 1.36]1,079  
 Wasting1.96[1.26, 3.05]2021.87[1.20, 2.91]1.65[1.12, 2.42]
 Underweight1.49[1.10, 2.00]702  

Table 3 shows the results for the hypothesised determinants of malnutrition. Adjusting for sex and age, extreme poverty was associated with increased risk of stunting and being underweight, but not with wasting, possibly because the latter is a short-term condition. The pattern of association with not having a child health card was similar. Vaccinations showed no effects, but recent illness was positively associated with all indicators of malnutrition. For those who had been sick with an ARI in the past 2 weeks, treatment showed non-significant detrimental effects. There were no associations between sleeping under a bednet and the malnutrition indicators, perhaps because of the small numbers in the population as a whole who had bednets. The effects of OVC status on children's risk of stunting and being underweight were altered little when these more proximate determinants of malnutrition were taken into account.

Table 3.   Determinants of stunting (A), wasting (B) and underweight (C) in children aged 6–59 months and contribution to association between OVC status and malnutrition
DeterminantUnivariate (non-OVCs) Test for differencenMultivariate (non-OVCs)† Test for differenceMultivariate (including OVCs) Test for difference
OR95% CIOR95% CIOR95% CI
  1. †Most parsimonious model (variables non-significant at the 90% level are dropped using reverse step-wise logistic regression)

A Determinants of malnutrition (stunting)
 OVC1.24[1.09, 1.41]1540 1.21[1.07, 1.38]
Socio-economic factors
 First quintile (wealth index)1.19[1.00, 1.42] 7551.16[0.97, 1.38]1.29[1.12, 1.49]
Poorer care – basic needs
 Did not sleep under bednet1.01[0.63, 1.62]3819   
Poorer care – healthcare
 No child health card1.40[1.06, 1.84] 2461.39[1.05, 1.82]1.22[0.97, 1.54]
 Incomplete vaccinations1.24[0.60, 1.08] 341  
 ARI not treated outside home0.85[0.42, 1.73]  50  
Frequent infections
 Diarrhoea in past 2 weeks1.27[1.05, 1.52] 6941.24[1.03, 1.50]1.26[1.08, 1.46]
 ARI1.05[0.80, 1.40] 259  
B Determinants of malnutrition (wasting)
 OVC1.10[0.84, 1.44]1552 1.08[0.83, 1.42]
Socio-economic factors
 First quintile (wealth index)1.19[0.84, 1.68] 753  
Poorer care – basic needs
 Did not sleep under bednet0.75[0.32, 1.75]3829  
Poorer care – healthcare
 No child health card0.48[0.22, 1.04] 248  
 Incomplete vaccinations1.06[0.58, 1.54] 341  
 ARI not treated outside home0.54[0.15, 1.90]  53  
Frequent infections
 Diarrhoea in past 2 weeks1.55[1.12, 2.16] 6931.50[1.08, 2.09]1.35[1.02, 1.79]
 ARI1.92[1.23, 3.01] 2541.83[1.17, 2.88]1.60[1.08, 2.36]
C Determinants of malnutrition (underweight)
 OVC1.18[1.02, 1.36]1558 1.15[0.99, 1.33]
Socio-economic factors
 First quintile (wealth index)1.27[1.04, 1.54] 7561.24[1.02, 1.51]1.22[1.04, 1.44]
Poorer care – basic needs
 Did not sleep under bednet0.91[0.54, 1.54]3892  
Poorer care – healthcare
 No child health card1.30[0.96, 1.77] 254  
 Incomplete vaccinations1.07[0.68, 1.30] 352  
 ARI not treated outside home0.79[0.38, 1.62] 100  
Frequent infections
 Diarrhoea in past 2 weeks1.67[1.37, 2.03] 7061.62[1.33, 1.98]1.55[1.31, 1.83]
 ARI1.52[1.13, 2.04] 2591.43[1.06, 1.92]1.30[1.01, 1.66]


Young orphans and vulnerable children are more likely to suffer from diarrhoeal disease, ARI, stunting and being underweight, independent of poverty and other potential confounders. Diarrhoeal disease and ARI were more common in non-orphaned children (6–59 months) living in households with a sick or recently deceased adult or headed by a child under 18 years of age, than in other children. However, young orphans did not appear to suffer from more frequent illness. Stunting and being underweight were more common in OVC than in non-OVC, and were most common in double and maternal orphans.

Findings from other studies on the health and nutritional status of OVC have been variable. Studies showing similar results to our findings (Bledsoe et al. 1988; Oni 1995; Sarker et al. 2005) have also reported higher morbidity and/or malnutrition in orphans compared with non-orphans However, there are also studies showing contrasting results (Ryder et al. 1994; Panpanich et al. 1999; Lindblade et al. 2003), indicating that there is no difference in the health or nutrition outcomes for OVC compared with non-OVC.

Extreme poverty was associated with increased occurrences of diarrhoea, stunting and being underweight, but no associations were found with ARIs or wasting. An incomplete vaccination record was associated with greater risk of diarrhoeal disease. The absence of associations observed between poverty and healthcare and ARIs and wasting may be because these conditions are relatively uncommon and, in the case of wasting, short-lived; hence, the sample size is too small to investigate the impact.

The main finding was that, while extreme poverty did increase the risk of diarrhoeal disease and chronic malnutrition (best indicated by stunting and less so by being underweight), differences in exposure to extreme poverty by OVC status were relatively small among young children. As a consequence, differences in poverty did not explain OVC's greater exposure to chronic malnutrition. Differences in healthcare between OVC and non-OVC existed, but were also found to contribute little to OVC health and nutritional disadvantage in the study populations.

Strong associations were found between the health and malnutrition indicators, confirming the synergistic relations between these conditions (Osuntokun 1976; Tomkins et al. 1989; Guerrant et al. 2000; Jukes et al. 2002). However, the cross-sectional nature of the data made it difficult to disentangle the inter-relationships and may obscure the true effects of poverty and differential access to treatment. Clearly, children in poorer households are at higher risk of disease and malnutrition (Brundtland 1999; Schellenberg et al. 2003; Zere & McIntyre 2003; Thuita et al. 2005) and, at the same time, a death in the household might subject a child to poverty. Differences in the prevalence of HIV infection between OVC and non-OVC and by way of OVC experience could not be investigated with the Zimbabwe OVC Baseline Survey 2004 data, and may also account for some of the unexplained variations in children's health and nutrition. With the continued rising incidence and prevalence of orphans in Zimbabwe (Watts et al. 2005), it is important to understand how adverse effects of poor health and malnutrition are affecting OVC. Our main finding from this cross-sectional survey is that greater malnutrition and ill-health seen in OVC were not explained by differences in exposure to extreme poverty. Findings from cross-sectional studies are important, as they provide potential directions for further investigation in this poorly researched area. Further research, in the form of longitudinal studies, is needed to understand the complete dynamics of how orphanhood and child vulnerability leads to such adverse outcomes.