Japan Journal

Japan Journal of
of Nursing
Nursing Science
Science (2016)
(2016) 13, 256–264 doi:10.1111/jjns.12105
doi:10.1111/jjns.12105

ORIGINAL ARTICLE

Exploring family-centered care for children living with HIV and

AIDS in Nigeria
Godwin ACHEMA and Busisiwe P. NCAMA
School of Nursing and Public Health, Howard College, University of Kwazulu Natal, Durban, South Africa

Abstract
Aim: To explored the role of family-centered care in supporting children living with HIV and AIDS in
Nigeria.
Methods: A qualitative research design was adopted for this study with a grounded theory approach.
Children aged between 11 and 14 years living with HIV and AIDS, their caregivers, and nurse practitioners
working in the HIV clinic were engaged in separate focus group discussions in two hospitals in Nigeria.
Results: The findings showed that the value African families place on children plays a significant role in
identifying their care needs and providing their basic necessities; hence, people around the sick child tend to
make him feel better, as attested by nurse practitioners and caregiver participants. Nurse practitioner
participants cited unified families as providing care support and love to the children and the support needed
to alleviate their sicknesses. Children participants confirmed that family members/relatives were always at
their disposal to provide supportive care in terms of administrating antiretroviral medication as well as other
psychological care; although a few participants indicated that disruption in family structures in resource-
poor settings, isolation and withdrawal, and deprivation of care due to poverty threatened the care rendered
to the children.
Conclusion: The study highlighted the value attached to children in the African context as helping family
members to identify the care needs of children living with HIV and AIDS; thereby providing succor to
alleviate their sicknesses and enhance their quality of life.
Key words: children, family-centered care, HIV/AIDS.

INTRODUCTION and for significant others in relation to the care of such

An increasing concern for households is disintegration
in family structures due to HIV and AIDS. This may
take the form of divorce, separation, or death among
couples with a seriously negative impact on the care of
vulnerable children who are themselves affected by HIV
and AIDS (Hosegood, 2009). The demise of parents or
caregivers of children infected with HIV has grave impli-
cations for pediatric HIV care for the family as a whole
Correspondence: Godwin Achema, School of Nursing and
Public Health, George Campbell Building, Howard College,
University of Kwazulu Natal, Durban 4041, South Africa.
Email: achemagoddi@gmail.com,
godwinachema@yahoo.co.uk
Received 30 March 2015; accepted 22 September 2015.
children (Saskatchewan Prevention Institute, 2013).
When families cannot meet the basic needs of children
living with HIV and AIDS, the role they play in care and
support will be compromised, making it important to
have community and other supportive care networks
(UNICEF], 2006).
Research by the Education Training Unit (2007) indi-
cated that stress experienced by caregivers in tackling
the extra burden of care for these children can be chal-
lenging, thereby degrading the provision of care and
support and potentially lead to abandonment, making it
necessary for other members of the extended family
network to provide succor. Against this backdrop,
family-centered care has become an important issue in
care support for children living with HIV and AIDS,
both to augment the care given at home-based levels and

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to promote psychosocial support and holistic care for
children and other family members (Mikkelsen &
Frederiksen, 2011).
Family-centered care views the family as a special
component in the delivery of healthcare services to the
sick child, and in delivering these services, adequate
collaboration between healthcare workers and family
members is necessary to foster interactions for a better
health outcome (Kovacs, Bellin, & Fauri, 2006; Shields,
Pratt, & Hunter, 2006). The family plays an integral
part in the treatment and care of the sick child, and
because family members collectively participate in
enhancing this care, it is crucial for them to have an
understanding of the child’s illness. The core principles
of care must be given substance in the relationship
between family members and healthcare professionals to
ensure an optimal health outcome for the child
(Johansen, 1994; Kohn, Corrigan, & Donaldson, 2001).
According to Ayieko (2003), loss of their parents and
ailments of HIV-affected caregivers cause orphans to
become separated from their families and caregivers.
They are deprived of affectionate care within the family
structure because older children leave the home setting
for other places where they have an opportunity to live
a better life. Rochat, Bland, Coovadia, Stein, and Newell
(2011) accordingly advocate comprehensive health care
with an integrated family-centered approach in provid-
ing supportive care to children and their individual fami-
lies, which would make it possible to ascertain the
complexities of the needs of the child in the context of
the family care structure.
Economic hardship associated with child inheritance
can create a burden within caregiver–family structures
for foster care given to children infected with HIV and
AIDS (UNICEF, 2002a). The difficulty that loss of
inheritance causes for child-headed households is a huge
problem for vulnerable children orphaned by HIV and
AIDS living in poorer households (Maqoko & Dreyer,
2008). Research has shown that to reduce the morbidity
and mortality of HIV-related conditions and address
other care challenges, these children living in poorer
households would need assistance in terms of medical
and emotional support within the confines of family-
centered care (Violari, Cotton, Gibb, Babiker, Steyn,
Madhi & McIntyre, 2008).
Research has also found that single parenting puts
children at risk of isolation or withdrawal, which is
likely to hamper efficient care given to them at the family
level (Goldman, Salus, Wolcott, & Kennedy, 2003).
Good coordination between families and community
members is necessary in order to map out strategies that
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could address treatment challenges and other param-
eters of care among children living with HIV and AIDS
(Adato & Bassett, 2009; UNICEF, 2011).
According to Farmer and Mignano (2011) comment-
ing on the challenges of family-centered care in the
Nigerian context, inadequate participation, vulnerabil-
ity of women, and abandonment are core factors ham-
pering family-centered approaches in the care of
children; in response, they advocate for interventions
that could address these challenges and promote acces-
sibility to healthcare in remote villages. In a similar vein,
Bhana, McKay, Mellins, Petersen, and Bell (2010)
propose the Collaborative HIV Prevention and Adoles-
cent Mental Health Program (CHAMP) as a model for
addressing the challenges of HIV-positive diagnosis
among children and adolescents in resource-limited set-
tings in Nigeria. Studying family dynamics would
provide the basis for a comprehensive family-centered
care approach in the care and treatment of children
infected with HIV and AIDS (Ehlers & Chiegil, 2011).
Even though family-centered care has had to face
many challenges over the years, it has now been
accepted as the bedrock of integrated care for children
living with HIV and AIDS in providing services that can
enhance health outcomes and in coping with the conse-
quences of HIV (Richter, 2010). The general well-being
of vulnerable children living with HIV and AIDS can
also be improved by a framework of family-centered
care focused on enhancing their quality of life
(DeGennaro & Zeitz, 2009). It is on these grounds that
family-centered care is appropriate to consider when
designing programs of intervention for prevention,
treatment, and care support for children living with HIV
and AIDS in African settings (Harrison, Newell, Imrie,
& Hoddinott, 2010; Sherr, 2010).
Against this background, the study was conducted to
investigate the nature of care given to children living
with HIV and AIDS in Nigeria in order to determine
what kind of care would be most appropriate and what
the underlying philosophy should be for such care. The
overall objectives of the study were to determine the
value of family life in the care of children living with
HIV and AIDS and to see whether there is inclusion of
families in the treatment and care services. This paper
reports on one aspect of the study.
METHODS
Design
A qualitative research design was adopted for this study
using the grounded theory approach proposed by
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Strauss and Corbin (1990) in a bid to analyze the role of
family members in looking after children infected with
HIV and AIDS. Nurse practitioners (NP), children, and
caregivers were engaged in separate focus group discus-
sions to ascertain the involvement of family members in
regard to the roles played by each of them in the care of
children living with HIV and AIDS. Synergy was main-
tained during focused group discussion sessions in a bid
to allow each participant to feel at ease and contribute
meaningfully in this study.
Participants
The study was conducted in two hospitals in Nigeria
(one faith-based health organization and one govern-
ment health institution). There was an initial sampling
of four participants among NP working on the
antiretroviral (ARV) unit from each of the hospitals, and
this sampling frame was built to theoretical saturation
of 10 members, making a total of 20 members for the
two hospitals. An initial sampling frame of four
members each for children and the caregiver partici-
pants was also adopted, which was built to theoretical
saturation of eight members each, making a total
number of 16 members for each hospital (i.e. eight chil-
dren and eight caregivers in each group). The partici-
pants gave written consent to participate in this study,
and the sampling strategy was guided by theoretical
principles and constructs in that participant selection
was based on emerging concepts as the study progressed
to ensure adequate representation (Polit & Beck, 2013).
Sample inclusion criteria
Child participants in this study had to be aged between
10 and 14 years, have had disclosure of their HIV status,
and be accessing ARV care at the time of the study.
Caregiver participants had to be either biological or
foster parents of these children and had to be involved in
their care. NP participants had to be working in the
ARV units and doing home visitation at the time of this
study. Support for the inclusion of children in the
research process is gaining prominence under the laws of
adoption and the family law, and any child above 10
years of age may give consent for it’s own adoption and
for other activities such as participating in research
(Family Law, 2011; Brown et al., 2011).
Relevance and acceptability
The relevance of this study is underpinned by the
increasing prominence of family-centered care in recent
research in recognition of the crucial role played by
families in the care of children infected with HIV and
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AIDS. The target population was deemed to be appro-
priate in view of their experiences in the care of children
living with HIV and AIDS and in relation to the percep-
tion of care within family constructs. The NP, the chil-
dren, and their caregivers had three separate focus group
discussions to get to theoretical saturation based on
emerging concepts as the study progressed. Studies per-
formed among vulnerable populations such as children
living with HIV and AIDS are ethically defensible if the
subjects stand to benefit from the research and if the
study is geared towards improvement of their health and
general well-being (Yan & Munir, 2004).
Data collection measures
The present authors’ university’s ethics committee
approved this study before the actual data collection
process began, and gatekeepers’ permission from
various health institutions where the study was con-
ducted was received; individual participants endorsed
informed consent to participate voluntarily in the study.
The principles outlined by Trochim (2006) were fol-
lowed in regard to ethical approval, which include
respect for persons, voluntary participation, giving
informed consent, protection from risk or harm, confi-
dentiality, anonymity, and institutional board review.
The data collection took place in a secluded apartment
in the ARV unit of each hospital to protect the partici-
pants from unnecessary questioning and undue expo-
sure. The faith-based health institution was tagged as
Hospital A and the government health institution was
tagged Hospital B. Data collection in qualitative
research is done in natural settings which gives an
opportunity to maximize the intensity of the phenom-
enon to be studied and the frequency under which that
phenomenon occurs (Burns & Grove, 2009; Morse &
Field, 1995).
The focus group discussions took approximately
1.5 h/session and the discussion guides were aligned
with the parameters of family care approach for children
living with HIV and AIDS in order to ascertain how the
care was being perceived. The participants received a
sum of 600 naira for transportation and there were
other gift items for children in participating in this study.
The period for the data collection was approximately 3
months (July–September, 2013).
Data analysis
The focus group discussions were audio recorded with
the permission of research participants, after which a
verbatim transcription of raw data was done with the
aim of attaching labels to the transcripts. Data analysis
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was done by the coding procedures proposed by Strauss
and Corbin (1998) comprising open, axial, and selective
coding. This was validated with the constant compari-
son method at every phase until theoretical saturation
was achieved (i.e. at the point where no further codes
and/or relationship emerges from the data). In line with
grounded theory procedures, data collection and analy-
sis were interrelated and done simultaneously to see the
emerging concepts before theoretical saturation. The
emerging codes, concepts, categories, and their subcat-
egories were ascertained to see the similarities, with
confirmation with other research findings to give a thick
description of the theoretical concepts.
FINDINGS
The identified themes extracted from the findings on
strengthening of family-centered care included value of
the care of the sick child, provision of love and care to
succor the child, and supportive care to alleviate their
sicknesses, while disrupted family structures with inad-
equate care, isolation and withdrawal, and threats of
poverty and deprivation were found to pose challenges
to family-centered care for children living with HIV and
AIDS.
Value of the care of the sick child
The findings identify family value of children in African
societies as the core issue in support of family-centered
care as members of the family take appropriate care of
these children at the home-based setting. The NP and
caregiver participants stated that this value was a crucial
element in identifying the care needs of the child
and providing the basic necessities, especially during
ill-health:
The family values the general care of children in our African
setting, so the family provides the necessities of children; the
family places value on the care of these children, and as such
interact with them at their levels, in order to identify the care
needs of the child. In African setting, when people are
around the sick child, the child tends to get better because,
there is this African saying that, “sickness runs away from
people”. (NP Participant 3; Hospital B.)
. . . our family places value on the care of children when they
are sick. (Caregiver Participant 2; Hospital B.)
Disrupted family structures with inadequate
HIV care in resource-limited settings
Although the value which families in African settings
attach to care of the sick child has very significant reper-
cussions on health outcomes, there were a few partici-
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pants in this study who indicated that disrupted family
structures with inadequate HIV care posed a challenge
to the care of these children in resource-limited settings.
The nurses cited disruption of family structure as nega-
tively influencing the family-centeredness of care that
health facilities could be rendering. The following quo-
tation from one of the nurses sums up this observation:
I had a client at the age of 12 years or there about who has
been accessing care here, an orphan, no father, no mother,
the only surviving sister has just graduated from school of
health technology here and brought her to the hospital for
the usual free treatment and we were told that they were on
admission and discharged 2 weeks ago and no money to pay,
so they have to get a loan to pay the hospital bill . . . now the
child is sick again, with the fear of going on admission for
doctor to officially see them, they say no, if the child is
treated, who is to pay; now they don’t want to disclose to
people because of the fear . . . what will they take this family
to be. (NP Participant 2; Hospital A.)
Provision of love and care to succor the
sick child
The findings further revealed that, living as a unit, fami-
lies tend to manifest love and care for the sick child;
hence, when the child has any problem, it is easily iden-
tified by family members and succor is provided within
that setting. The NP noted that when a child is sick, it is
seen as sickness that affects the whole family; as such,
other family members can come to visit and give encour-
agement in a bid to provide some level of assistance.
Even with admission to hospital, the family forms an
important part of the health team, which also provides
opportunities for educating the entire family on issues
around HIV and AIDS, including treatment options and
supportive care. The importance of love and care in the
family context in providing succor to the sick child was
also emphasized by some caregivers, especially for
orphaned children made vulnerable by HIV and AIDS:
Living together as one unit families helps in the care of the
sick child. In our society here, when a child is sick, it is seen
as the whole family is sick, so when another family visits
them, they will sit down, talk with them, encourage them,
others will even come with gift items; in this way they will
feel being loved. (NP Participant 2; Hospital B.)
When they come to the hospital, we interact with them, sit
with them and educate them that they are still useful in the
society; once they are thriving in their health, we also give
them health talk on the mode of transmission, not to play
around with opposite peers in sexual promiscuity . . .
sharing of blades such as needles and sharp objects as well as
taking screened blood when they are to go on blood trans-
fusion . . . we also educate them on the various treatment
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available for children infected with HIV and AIDS. (NP
Participant 9; Hospital B.)
These children need love and care especially those that
have no fathers and mothers. I mean the orphans
(Amomayekwu), the family care they need are sometimes
missing, the caregivers should foster these children totally.
(Caregiver Participant 2; Hospital A.)
Isolation and withdrawal due to HIV condition
with associated stigma
Isolation and withdrawal due to HIV condition (causing
incapacity to care) coupled with stigma, were seen as
affecting the supportive care given to these children at
the family level, even though living as a single unit
family was a strong factor in providing love and succor
to the sick child. Among the findings, this point was
particularly emphasized by NP. The need for family
counseling was highlighted as an important component
in fostering family-centered care.
Some of the family members will accept the child with HIV
and AIDS, but some may not accept because of stigma and
discrimination. So the family needs good counseling to
understand the problem of the child. (NP Participant 10;
Hospital B.)
I want to say that we have one of our clients that absconded
from here because the family disown her because she was
positive . . . she was admitted here, so I have to trace the
family at their doorpost telling them that one of your family
members is on admission in Hospital X, so, so, and so and
they said, they don’t have anybody like that, that gone are
the days they have somebody like that, since she has gone
out with her condition, they have forgotten about her. (NP
Participant 2; Hospital A.)
Support given to children to reduce their
sicknesses
Echoing this finding from the study, caregivers and child
participants indicated that family members and other
relatives were always there to give the needed support
which had been of a great assistance in helping to alle-
viate their sicknesses through assistance with medication
and other supportive care:
The children are cared for by their family members, as in
giving them their drugs at the right time and also giving
them the necessary foods that can help to build their bodies
and protect them from illnesses. (Caregiver Participant 1;
Hospital B.)
Our family members and other relations live with us and
they take care of us; they help us to take our drugs and this
has helped us to reduce our sicknesses. (Child Participant 3;
Hospital B.)
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for HIV children
Our family members do help us a lot in our care, because,
they do not allow us to forget taking our drugs. . . they
remind us always, and when we need other care, they will
give us; they are happy with us and they do not want us to
be angry at all. (Child Participant 5; Hospital B.)
Threat of poverty and deprivation in
family-centered care
Some NP participants indicated that, due to inadequate
resources and the attendant problem of poverty within
the family structures, these children may be deprived of
the care that they should receive, and caregivers in such
circumstances may find it difficult to provide for the
basic needs of the child, possibly because of spousal
death or due to general impoverishment.
Well, the care, it varies, it depends on the financial capabili-
ties of each family as we are talking about the care . . . if
somebody is so poor, he will find it difficult, except his
relations come to help. (NP Participant 2; Hospital B.)
My own challenge rests on poverty, maybe you have four or
five children and your husband is no more alive and you
have no job, you cannot put them in school and this HIV
killed their father, so there will be a problem in caring for
them. (NP Participant 4; Hospital A.)
DISCUSSION
In responses from NP and caregiver participants, para-
mount emphasis was given to the value of family care
for the sick child in recognition that family members
tend to identify the needs of the child and provide
appropriate care when the need arises, and because the
sick child tends to feel better when people are at hand to
give encouragement and needed advice; hence, the
African saying that “sickness runs away from people”.
Leeper, Montague, Friedman, and Flanigan (2010)
confirm that, family-centered care plays a crucial role in
the care of children living with HIV and AIDS, because
involvement of family members in the care tends to
ensure good treatment outcomes. These authors urge
that there should be adequate family involvement in
intervention programs for supportive care so that other
challenges of HIV among these children can also be
addressed. The International HIV/AIDS Alliance (2012)
recommends family-centered care as the optimal care
choice for the child living with HIV and AIDS, because
members of the family live with the child and can there-
fore easily identify their care needs and provide holistic
care in terms of nutrition, education, and other services.
Another finding in the study was that HIV/AIDS nega-
tively impacts upon families in resource-limited settings
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due to issues of inadequate care coupled with other
factors that affect the ability of the family structure at
the household level to accommodate caring for vulner-
able children (Rochat et al., 2011). Low-income coun-
tries presented with disrupted social structures among
families, which incapacitates the family network in
caring for HIV-infected children. Violence and disasters,
as experienced in some African countries, invariably
weaken the family structure needed to cater for the
needs of the child (Mathambo, Gibbs, Richter, & Sherr,
2008).
In providing love and care to succor the sick child, NP
and caregivers made the point that, in African societies,
when a child is sick, the whole family is affected; the
family thus carries the burden of care and provides the
needed help for the survival of the child and this is
possible because in African settings the family members
live with the children. The caregivers confirming this
point emphasized that family-centered care for orphans
is all the more important because of their vulnerability.
There is a strong emotional tie between children and
their parents in the African family context, as members
of the family live together and share their problems, and
this bond is embedded in the extended family system
which includes aunts, uncles, grandparents, and neigh-
bors, and promotes mutual commitment to one another
in shared responsibility for the care of the child (Bharat,
1999; Krishna, Bhatti, Chandra, & Juvva, 2005). Issues
relating to the culture of African family structures also
mean that orphans and vulnerable children with HIV
and AIDS need counseling and psychosocial support
from time to time to enhance their care (Southern Africa
HIV and AIDS Information Dissemination Service/
United Nations for International Developments
[SAFAIDS/UNAIDS], 2000). Studies have shown that,
the physical and psychosocial support which children
living with HIV and AIDS need in their coping strategies
is provided by the African family network (Heymann,
Earle, Rajaraman, Miller, & Bogen, 2007; Makoae
et al., 2005). When a child is found to be infected by
HIV, the whole family is considered to be affected and
rallies round to provide the care and support needed by
the child (Rotheram-Borus, Flannery, Rice, & Lester,
2005). In African settings, there is a collective responsi-
bility among families in taking care of the sick which is
clearly reflected in the way caregivers in poorer house-
holds take care of children, especially those orphaned by
HIV and AIDS (UNAIDS 2006).
Even though the family structure helps to provide the
needed love and care for children infected with HIV and
AIDS, the study findings also showed that isolation and
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withdrawal caused by HIV, coupled with stigma and
other associated factors, can impinge on the supportive
care given to these children when, in some cases, families
and other people connected with the client may not like
to be associated with the HIV condition. Nga Tran and
Mwanri (2013) found that HIV-related stigma among
peers and parents can grossly affect the care given to
children living with HIV and AIDS at the family/
community setting, and in the study by Beard et al.
(2010), capacity to care for children of sex workers
living with HIV and AIDS was truncated because their
parents did not want to associate with their wards,
creating an obstacle to the family-centered approach in
their caring patterns.
Caregiver and child participants citing the support
and assistance given by family members in alleviating
the illnesses of children living with HIV and AIDS made
particular mention of help given in taking medications
appropriately together with other psychological support
to alleviate anxiety that could aggravate the illness. A
study conducted in Nigeria by Alubo, Zwander,
Jolayemi, and Omudu (2002) reported that if a child is
diagnosed with HIV in a family setting, the entire family
and/or household is said to be an AIDS family, with the
onus of care resting on that family; supportive care is
then able to draw on the cohesion that characterizes
African family settings, as the concerns of the infected
child become a personal concern for each family
member. In a similar finding, Iwelunmor, Airhihenbuwa,
Okoror, Brown, and Belue (2006) noted that in southern
African communities, bonding between the parents and
their children meant that the family system provided a
supportive network in terms of emotional care, home
support, and financial assistance to relatives and chil-
dren infected with HIV and AIDS.
The study also indicated that inadequate resources,
coupled with poverty among caregivers in the family
setting, incapacitated the care with family structure net-
works becoming increasingly inadequate to cater for the
numbers of vulnerable children orphaned by HIV and
AIDS. UNICEF (2002b) reported an associated poverty
with HIV/AIDS epidemic in Nepal among the caregivers
which negatively impacted the care of vulnerable chil-
dren affected by HIV and AIDS; most of the children
were faced with nutritional, health and educational
challenges, and some of them were forced to take to the
streets without proper care. Similarly, Human Rights
Watch (2005) submitted that HIV-infected orphans were
forced to drop out of school due to poverty of the
caregivers making them vulnerable as street children to
earn a livelihood; the poverty-stricken parents could not
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afford the basic necessities such as uniforms, books, and
other materials for their education. Among poorer
households in southern African communities, orphans
and other vulnerable children living with HIV and AIDS
who are deprived of physical and social support are in
some cases forced to take on adult roles in heading
households that are disadvantaged by lack of resources
coupled with exploitation within the extended family
network (Gillespie, 2006). Against this backdrop,
studies have shown that children infected with HIV and
AIDS need love, affection, and care because of the chal-
lenges that accrue from the nature of their illness; in
striving to cope with the consequences of HIV, family
members and other caregivers must therefore be cogni-
zant of this aspect of care in providing support, espe-
cially to the orphans who live in poorer households
(Summers, Kates, & Murphy, 2002; UNICEF, 2005).
CONCLUSION AND
RECOMMENDATIONS
Principally highlighted in the study is that the value
attached to children in the African context, especially in
the Nigerian setting, helps family members to identify
the care needs of children living with HIV and AIDS,
thereby providing succor to alleviate their sicknesses and
enhance their quality of life. Emerging from the overall
context of the study is a theory of empathic supportive
care in the spirit of ubuntu, for reinforcement of family-
centered care among children living with HIV and AIDS.
A family-centered model is advocated with positive
involvement of family members and significant others in
the care of children living with HIV and AIDS from
clinic phase to the home-based level in view of the
crucial roles they play in the convalescence of these
children.
Implication for Practice
The current study reflects the way family-centered care
influences the care of children living with HIV and AIDS
in African family settings and especially in the Nigerian
context where this study was conducted; the implication
for nursing practice is that family members need to be
involved in the care of children infected with HIV and
AIDS right from the planning phase, and collaborate
with other stakeholders, so as to facilitate care from the
clinic to the home-based care setting. Family members
and significant others can be a crucial component of the
supportive systems in the care of these children.
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ACKNOWLEDGMENTS
The authors acknowledge the contributions of the
College of Health Sciences and School of Nursing and
Public Health, Howard College, University of Kwazulu
Natal, Durban, South Africa, in carrying out this
research project and in disseminating the findings of the
study. The authors also acknowledge the contributions
of the NP working on the ARV units of Grimard Hos-
pital Anyigba and General Hospital Ankpa as well as the
Social Service Workers and Reverend Sisters working
with the Kogi State Agency and Diocesan Action for the
Control of AIDS, Nigeria, for supporting us with logis-
tics in carrying out this research.
CONFLICT OF INTEREST
There is no conflict of interest to disclose as per the
authors involvement either financially or otherwise
which may potentially bias this work; therefore, the
authors declare an absence of any interest in the conduct
of this study.
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