Date Published: Dec. 17, 2009

DURHAM, N.C.—A Duke University study of more than 3,000 orphaned and abandoned children in five Asian and African countries has found that children in institutional orphanages fare as well or better than those who live in the community.

The findings contrast sharply with research that associates institutions with poorer health and well-being, and the policies adopted by many international agencies/governments. “Our research is not saying that institutions are better. What we found is that institutions may be a viable option for some kids,” said study leader Kathryn Whetten, director of the Center for Health Policy at the Duke Global Health Institute. “As the number of orphans continues to rise worldwide, it is vital not to discount orphanages before assessing whether they are harmful to the millions of children for whom they care.”

Whetten’s research team compared the physical health, cognitive functioning, emotion, behaviour and growth of orphaned or abandoned children ages 6-12, half of them living in institutions and the other half dwelling in the community. The study found that children in institutions in five countries reported significantly better health scores, lower prevalence of recent sickness and fewer emotional difficulties than community dwelling children. These findings suggest the overall health of children in orphanages is no worse than that of children in communities.

The research team has been following the 3,000 orphans involved in the study for three years, and they plan to continue tracking them into their late teens and early 20s to determine how their childhood affects their life course.

Published Friday in the interactive open-access journal PLoS ONE, this is one of the most comprehensive studies of orphans ever conducted. Data were collected between May 2006 and February 2008 from children and their caregivers in 83 institutional care settings and 311 community clusters. The study assessed five culturally, politically and religiously-distinct countries that face rising orphan populations. Sites included Cambodia, Ethiopia, Hyderabad and Nagaland in India, Kenya, and Tanzania.

“Very few studies cross a span of countries like ours does,” said Whetten. “The design flaw of past studies is that they compared a small number of orphanages against community houses. Those limited results can’t be generalized to other places.”

Some of the most influential studies on child institutions were conducted in eastern bloc countries. But the greatest burden of orphans and abandoned children is in sub-Saharan Africa and Southern and Southeastern Asia.

Of the estimated 143 million orphans and abandoned children worldwide, roughly half reside in South and East Asia, according to UNICEF. An estimated 12 percent of all children in Africa will be orphaned by next year as a result of malaria, tuberculosis, pregnancy complications, HIV/AIDS and natural disasters, according to the World Health Organization.

The Duke study included less formal institutions in Asia and Africa that were not studied before, and not easily recognized. Researchers spent the first six months meeting with members of each community to identify and map orphanage locations. In Moshi, Tanzania, the research team found 23 orphanages, after initially learning of just three from local government officials.

“What people don’t understand is that, in many cases, the institutions are the community’s response to caring for orphaned and abandoned children,” said Whetten. “These communities love kids and as parents die, children are left behind. So, the individuals who love children most and want to care for them build a building and that becomes an institution. These institutions do not look or feel like the images that many in this country have of eastern bloc orphanages, they are mostly places where kids are being loved and cared for and have stable environments.”

The research findings run contrary to global policies held by children’s rights organizations such as UNICEF and UNAIDS, which recommend institutions for orphaned and abandoned children only as a last resort, and urge that such children be moved as quickly as possible to a residential family setting.

“This is not the time to be creating policies that shut down good options for kids. We need to have as many options as possible,” said Whetten. “Our research just says ‘slow down and let’s look at the facts.’ It’s assumed that the quality of care-giving is a function of being institutionalized, but you can change the care-giving without changing the physical building.”

Whetten said more studies are needed to understand which kinds of care promote child well-being. She believes successful approaches may transcend the structural definitions of institutions or family homes.

“Let’s get beyond labeling an institution as good or bad,” she said. “What is the quality of care inside that building, and how can we help the community identify cost-feasible solutions that can be delivered in small group homes, large group homes and family homes?”

The study was supported by grants from the National Institute of Child Health and Development. Other Duke researchers involved in the study include Rachel Whetten, Jan Ostermann, Nathan Thielman, Karen O’Donnell, Brian Pence and Lynne Messer.
PLoS One: “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6-12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations.”

Date Published: March 25, 2011

A new study by Duke University researchers calls for increased support, protection and appropriate mental health services for orphaned and abandoned children on a global scale.

Published in the Journal of Traumatic Stress today, the study of more than 1,200 orphaned and abandoned children across five low- and middle-income countries is one of the first to identify and quantify violence, physical and sexual abuse as other potentially traumatic events endured by orphans, after having lost one or both parents.

Led by Kathryn Whetten, director of the Center for Health Policy and Inequalities Research at the Duke Global Health Institute, the study shows that 98 percent of the orphaned and abandoned children surveyed had experienced more potentially traumatic events than “simply” the loss of their parent, with more than half experiencing four or more such events.

Children reported such traumatic events as physical and/or sexual abuse, the death of other family members and witnessing family violence. The study found increased traumatic events during childhood were linked to statistically significant increases in anxiety and emotional and behavioral difficulties that can last into adulthood and result in poor performance in school.

Researchers suggest that further traumatic events could be averted with early and community-wide interventions and mental health care. The study indicates children and caregivers are willing to discuss these events with trained interviewers.

Authors of the paper point to the need for protection policies and development of coping skills for both girls and boys, since their data shows young boys are just as vulnerable as girls for experiencing all forms of traumatic events, including abuse. Children who have lost both parents are considered most vulnerable and appear to be most negatively affected by repeated exposure to potentially traumatic events.

With an estimated 150 million orphaned and abandoned children worldwide, these research findings are particularly relevant for ensuring this group’s overall long-term health and well-being.

“We know that increased rates of childhood abuse result in increased substance abuse and high risk sexual activity later in life,” Whetten said. “If this occurs within the population of orphaned and abandoned children, it will result in a very large cohort of children who will be at a higher risk for contracting HIV/AIDS and other sexually-transmitted diseases, and reduced health promotion activities. “So, our study has important policy implications for clearly laying out the needs of orphaned and abandoned children early, before the situation escalates in adulthood.”

A recent conference hosted by the United State Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR) stressed the need for orphaned and abandoned children to be cared for in family settings around the world. The conference also recognized that social welfare and child protection organizations in low- and middle-income countries are poorly funded and not well-respected.

“It is clear that food, water, shelter, educational support and health care services are necessary, but that’s not sufficient for the orphan population. The well-being of these children depends on their physical and emotional safety, and they need protection,” Whetten said.
“Sustainable national social service systems and others social service agencies need to be strengthened to be able to ensure that orphaned and abandoned children are able to live in safe environments. While we have done much to strengthen health care systems and it is a continued focus with broad-based support, we must not neglect protective systems.”

The study is part of the Positive Outcomes for Orphans (POFO) study being conducted in Cambodia, India, Ethiopia, Kenya and Tanzania. Other Duke researchers, working alongside POFO research teams in each country include Jan Ostermann, Rachel Whetten, Karen O’Donnell and Nathan Thielman.

For more information on the study, the POFO research teams in each region, and other publications, visit the POFO website.

Date Published: Jan. 18, 2011

One in seven orphaned and abandoned children (OAC) in low- and middle-income countries is engaged in child labor, according to new research by DGHI researchers. With such organizations as UNICEF declaring that child labor is harmful and should be eliminated, the cross-cultural study calls on policy makers and social service providers to pay close attention to the demands being placed on orphaned and abandoned children, particularly in rural areas and poor households with limited income sources.

The Positive Outcomes for Orphans (POFO) research project led by Kathryn Whetten at DGHI’sCenter for Health Policy, is among the first to quantify the prevalence of child labor among OAC in low- and middle-income countries. The study includes 1,480 orphaned and children abandoned by one or both parents ages 6-12 living in family settings in Cambodia, Ethiopia, India, Kenya and Tanzania.

In a newly published paper in BioMed Central by lead author Rachel Whetten, POFO researchers found that children who tended to work more were female, healthy, lived in rural settings, and/or had caregivers who had no income. Another significant finding is a strong association between increased child labour and decreased school attendance.

Whetten’s research team conservatively found 60% of OAC engaged in work during the past week, and of those who worked, about 18% worked 28 or more hours. More than a fifth of the total children sampled met UNICEF’s definition of child labor, which is work that exceeds a minimum number of hours depending on the age of the child and type of work. For children ages 5-11, child labor is defined as at least one hour of economic work or 28 hours of domestic work per week. For children ages 12-14, child labor is defined as at least 14 hours of economic work or 28 hours of domestic work per week.

“The very definition of labor is considered in this study, as in what is defined as labor versus chores, the argument being that household chores are not always measured as ‘work’ or ‘labor’ but are almost universally assigned to females, such as child care, water fetching, cooking or cleaning,” said Rachel Whetten of the labor study, which included household chores that exceeded the minimum number of hours per week. “One of the striking conclusions of this study is that female children are twice as likely as male children to be engaged in child labor. This supports the argument made by child protection and policy making organizations that when unpaid domestic ‘chores’ are not counted as labor, we risk missing the large burden being placed on children, particularly female children, which can interfere with their educational attainment and future well-being.”

With an estimated 143 million orphans worldwide, the research has implications for global policy makers and child service providers in low- and middle-income countries. POFO researchers suggest that programs to promote school attendance among orphaned and abandoned children may need to focus on the needs of families holistically as well as the needs of the children. Additionally, Rachel Whetten urges policy makers and care providers to consider the reality that female children are in great need of additional services and aid.

Other researchers for this study include Lynne Messer, Jan Ostermann, Brian Pence, Megan Buckner, Nathan Thielman and Karen O’Donnell.  The study was funded by the National Institute of Child Health and Development.

The study is available here.

Date Published: Aug. 24, 2010

A group of researchers at the Center for Health Policyhave found greater acceptance of orphans and abandoned children (OAC) in institution-based care as opposed to community-based care, according to a study of 2,000 caregivers of OAC in five less wealthy nations.

The study found that 84% of institution-based caregivers compared to 66% of community-based caregivers said they would be willing to care for a relative with HIV. A similar disparity was evident for the proportion of caregivers who said they would be willing to let their child play with an HIV-infected child (81% vs. 64%).

These findings challenge recent policy statements that have recommended de-emphasizing institution-based care in favor of community-based care settings on the basis that better child care will result. Further research on the prevalence of HIV-related acceptance and stigma among caregivers and implications of such stigma for child development will be critical as the policy community responds to the global HIV/AIDS orphan crisis.

Authors of the paper published this month in BMC Public Health include Lynne Messer, Brian Pence, Kathryn Whetten, Rachel Whetten, Nathan Thielman, Karen O’Donnell, and Jan Ostermann.