Abstract
BackgroundWith more than 2 million children living in group homes, or “institutions”, worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers.MethodsA two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6–12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites.FindingsAt 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11–27% of total variation) or care settings within sites (8–14%), with most variation attributable to differences between children within settings (60–75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0–4% at baseline, 0–3% at 36-month follow-up, and 0–4% for changes between baseline and 36 months.InterpretationThese findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting.
Highlights
Low and middle income countries (LMICs) [1] are home to an estimated 132 million single and double orphans, 95% of whom are over the age of five [2]
Study Description Positive Outcomes for Orphans (POFO) is an ongoing longitudinal study following a cohort of children, starting at ages 6 to 12, living in institutional or familybased settings in six sites in five low and middle income countries: Battambang District, Cambodia; Addis Ababa, Ethiopia; Bungoma District, Kenya; Nagaland and Hyderabad, India; and Kilimanjaro Region, Tanzania
Within the six study sites, the POFO study utilized a two-stage random sampling methodology to identify a representative sample of 1,357 orphaned and separated children (OSC) living in institutional settings and 1,480 OSC living in family-based settings
Summary
Low and middle income countries (LMICs) [1] are home to an estimated 132 million single and double orphans, 95% of whom are over the age of five [2]. [3] More than two million children are estimated to live in ‘‘institutions’’ [4], a term used broadly in policy and program planning documents to define group homes where children from multiple families live with biologically non-related caregivers. The variability of these group homes is remarkable, ranging from small residences with long-term live-in caregivers, to large facilities with multiple family-like units, to very large facilities with caregivers working in shifts and without assigned responsibility for individual children [5,6,7]. With more than 2 million children living in group homes, or ‘‘institutions’’, worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers
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