Study Title: Positive Outcomes for Orphans (POFO): Longitudinal study of orphaned and abandoned children (OAC) from ages 6-12 to ages 15-21 living in 6 diverse settings 

Context: International policymakers are struggling to find solutions for the estimated 153 million children worldwide who have had at least one parent die, largely due to high mortality rates from conditions such as malaria, tuberculosis, HIV/AIDS and pregnancy complications. Millions more do not know the whereabouts of their parents. In light of the large presence of orphaned and abandoned children, especially in low- and middle-income countries continued research is needed that allows policy makers and providers to understand and develop locally feasible and appropriate ways to care for the children.

Study Aims: Positive Outcomes for Orphans (POFO) is longitudinal study conducted in five countries over a period of 9-10 years thanks to 2 consecutive National Institutes of Child Health and Development (NICHD) funded studies. OAC were ages 6-12 at baseline and will be ages 15-21 at the conclusion of the study. This unique population-based study is the only one of its kind that follows orphaned and abandoned children (OAC) for up to 9 years in culturally and structurally diverse settings allowing for a glimpse into what current care options are and the effects of that care and other life events over time on: health, cognition, emotion, educational attainment, labor force participation (including forced labor), sexual risk taking, marital patterns and community engagement. 

Methods: OAC ages 6-12 and living in family settings were recruited from six diverse study areas in five countries: Addis Ababa (Ethiopia), Bungoma District (Kenya), Kilimanjaro Region  (Tanzania), Battambang District (Cambodia), and Hyderabad and Nagaland  (India) (N=1480). The sampling strategy involved the selection of 50 sampling areas (‘‘clusters’’) at each site and five OAC from each cluster. From comprehensive lists of residential facilities in study area, 83 facilities were randomly selected for including in the study with 1,357 OAC then randomly selected from lists of children of the appropriate age from each facility. Baseline assessments were collected for children and caregivers being in May 2006: enrollment continued for 22 months. OAC were defined as children who had at least one parent die or who were abandoned by both parents. In households with multiple eligible children, one child was selected as the child whose first name started with the earliest letter in the alphabet. Interviews with children’s self-identified primary caregivers were conducted in their respective native language in the child’s residence. Six-month follow-up assessments were conducted in 5 of the 6 study sites and 12-months follow-up assessments in all sites. Interview windows for follow-up assessments were open from one month prior to two months after the scheduled follow-up date.

Policy Implications:

  • The study seeks to determine which environmental characteristics (e.g. home, community, culture, social networks, etc.) promote positive and negative outcomes for OAC as they transition through to young adulthood. With this knowledge, more appropriate local, national and international policies can be created for this age group and appropriate care options can be more actively supported.
  • The study will seek to examine how personal factors, including life events, (e.g. number of potentially traumatic events experienced, emotional health, and cognitive development) affect orphans and identify potential interventions that could improve outcomes for the adult lives of orphans.

Principal Investigator: Kathryn Whetten (Duke University)

Investigators: Bernard Agala (Duke University), Cyrilla Amanya (ACE Africa, Kenya), Misganaw Eticha (SVO Ethiopia), Amy Hobbie (Duke University), Dafrosa Itemba (TAWREF, Tanzania), Rachel Manongi (KCMC, Tanzania), Lynne Messer (Duke University), (KCMC, Tanzania), Karen O’Donnell (Duke University), Jan Ostermann (Duke University), Brian Pence (Duke University), Nathan Thielman (Duke University), Vanroth Vann (Homeland, Cambodia), Augustine Wasonga (ACE Africa, Kenya), Rachel Whetten (Duke University)

Contact Information: duke.ovcstudies@gmail.com

Study Title: Explaining the Expansion of Institutions in Battambang Province

Context: According to a 2009 UNICEF statistic, there are an estimated 630,000 orphans in Cambodia, 12,000 of whom currently reside in orphanages. Although some institutions provide services specific to the needs of certain populations of vulnerable children (victims of sexual trafficking, children living with HIV, street children, and children with disabilities), a 2011 UNICEF report revealed that a majority of the 12,000 children in Cambodia’s orphanages have one living parent; 28% of children in orphanages have lost both parents. Furthermore, the number of children in care has more than doubled in five years. In Cambodia’s northwest province of Battambang, the number of orphanages has more than quadrupled from 11 to 45 over the last decade.

Study Aims: This study aims to better understand the reasons for institutional expansion in Battambang Province. Through a series of qualitative interviews with orphanage directors and caregivers, the study will help us to understand the reasons underlying the expansion in the number of orphanages in the region.

Methods: A stratified random sample of 15 orphanages in Battambang was contacted for participation in this study.  Orphanages were stratified based on four criteria: size, length of presence in the province, foreign/locally-run institutions, and religious affiliation. A series of 45-minute interviews are being conducted with the directors of selected institutions to better understand the reasons that they opened the institution, why children are sent to live in orphanages as well as to learn more about the services provided by these institutions. A small sample of 7-10 parents/caregivers in the Ek Phnom District will also be interviewed to gain more direct information about the reasons why Battambang Province families send their children to institutions.  Questions regarding the socio-economic background of the family, the reasons for sending children to institutions and the perception of need in the local community will be asked of each participant.  The participating individuals will be the parents/caregivers of scholarship students at the Khmer Center for Development (an afternoon-English program in Ek Phnom District, Battambang Province) whose child/children is/are currently placed in institutional care.

Policy Implications:

  • The study will provide relevant information regarding why orphanages are being opened at such a quick pace in the Battambang region. This knowledge could lead to similar studies in other areas.

Principal Investigator: Leila Dal Santo (Duke University)

Investigators: Vanroth Vann (Homeland, Cambodia), Kathryn Whetten (Duke University)

Contact Information: duke.ovcstudies@gmail.com

 

Study Title:  Child transitions from residential facilities to other communities: predictors of child wellbeing 

Context: Globally, one hundred and fifty three million children are estimated to have been orphaned as defined by the death of one or both parents due to diseases such as malaria, tuberculosis, and cancers, maternal mortality, unintentional injuries, natural disasters and armed conflict: AIDS accounts for 16.6 million of these children. We can anticipate that numbers of orphaned children will increase with factors such as economic declines, decreased agricultural output due to environmental changes and increased natural disasters. In Ethiopia, an estimated 650,000 children have lost one or both parents to AIDS. The majority of orphaned children and children whose biological parents have left them are cared for by the remaining parent, other family members, or non-relatives in family settings: a small proportion live in residential facilities

Study Aims: The primary goal of this pilot study is to understand the emotional and physical well-being of children transitioning out of residential care to better inform good policy and practice on the protection of children. The intent is to understand factors associated with positive and negative transition outcomes. Care transitions occur for a variety of reasons, such as family placement, aging out (reaching the maximum age allowed in residential facilities), child self-initiated departures, community or family initiated retrievals, residential facility initiated expulsions, and residential facility closures.  This study attempts to assess children’s mental and physical well-being while still living in residential care and then follow them out of residential facility care into other living environments.

Methods: This initial study is designed to determine the feasibility of finding, following and maintaining communication with children as they leave residential facilities, to examine the different living environments they transition into, and to examine if there are trends or associations in how well transitions are made. In particular, pre-transition child characteristics (e.g., age of entry into residential care, years in residential care, age at placement in a community setting), facility characteristics, transition planning characteristics, community placement characteristics, and child wellbeing outcomes will be analyzed and compared to data from matched controls in community-family settings.  Short-term descriptive information such as documenting the range of living environments children transition into is vital.  However, short-term outcomes may not reflect longer-term physical or emotional trends.  If the pilot study methodology proves successful, i.e., children are able to be followed over time and useful measurements obtained, a longer, multi-country longitudinal study will be proposed.

Policy Implications:

  • To examine the positive and negative physical and mental health trajectories of children and young adults transitioning out of residential facility care for a variety of reasons, including residential facility closures, aging out and self-other initiated departures.
    • To determine how different types of residential facility-to-community transition experiences (e.g., types of preparation, planning process, availability of resources) affect children and families’ mental and physical wellbeing.
    • To better understand associations between characteristics of the residential facilities and post-residential facility care, and child emotional, physical and social well-being before and after re-location.
    • If the pilot study methodology proves successful and children are able to be followed over time, researchers may propose a larger multi-country study.

Principal Investigator: Sumi Ariely (Duke University)

Investigators: Misganaw Eticha (Stand for the Vulnerable Organization, Ethiopia), Charles Nelson (Harvard University), Jan Ostermann (Duke University), Lorraine Sherr (University College London),  Kathryn Whetten (Duke University), Rachel Whetten (Duke University)

Project Coordinator: Andrew Goodall

Contact Information: duke.ovcstudies@gmail.com

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 WhettenJan OstermannNathan ThielmanKaren O’DonnellBrian 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 OstermannRachel WhettenKaren 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 MesserJan OstermannBrian 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.

Designing household survey questionnaires for developing countries: Lessons from 15 years of the Living Standards Measurement Study

Abstract: The objective of this book is to provide detailed advice on how to design multi-topic household surveys based on the experience of past household surveys. The book will help identify define objectives, identify data needed to analyze objectives, and draft questionnaires to collect such data. Much of the book is based on the experience of the World Bank’s Living Standard’s Measurement Study (LSMS) program, established in 1980 to explore ways the accuracy, timeliness, and policy relevance of household survey data collected in low-income countries. It is part of an attempt to extend the range of policy issues that can be analyzed with LSMS data; to increase the reliability and accuracy of the surveys; and to make it easier to implement LSMS surveys. The books first discuss the “big picture” concerning the overall design of surveys, modules to be used, and procedures for combining modules into questionnaires and questionnaires into surveys. Individual modules are discussed in depth as well as major policy issues. The process of manipulating modules to form a better ‘fit’ in the case of a specific survey is examined. Specific modules include: consumption, education, health employment, anthropometry, non-labor income, housing, price data, environmental issues, fertility, household income, savings, household enterprises, and time use. The third volume provides draft questionnaires, referenced in the prior chapters.

Source: World Bank

Published: May 2000

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Whetten, Rachel

Position: International Sector Director at the Center for Health Policy and Inequalities Research (CHPIR)

Education: MPH, Health Behavior/International Health; 2001, University of North Carolina, Chapel Hill, NC. BA, Anthropology; 1996, State University of New York at New Paltz, NY.

Current Projects: Rachel is currently working on at variety of different research project at CHPIR. Her current project include: Positive Outcomes for Orphans (POFO), Coping with HIV/AIDS in Tanzania (CHAT), Tearfund Evaluation (Child Sexual Abuse Evaluation in Russia), and  Coping with HIV/AIDS in Russia (CHAR), among many

Background: Rachel directs all research activities within the International Sector of the Center for Health Policy and Inequalities Research (CHPIR) at Duke University. She is interested in international public health and health disparities research with a focus orphans and children, mental health, substance use and trauma. She has a particular interest in the cultures and people of the former Soviet Republic and Eastern Bloc countries.

Contact:

  • Email: rachel.whetten@duke.edu
  • Mail: 2812 Erwin Road, Suite 403; Durham, NC 27705

OVC Wellbeing Content:

Correlates of Poor Health among Orphans and Abandoned Children in Less Wealthy Countries: The Importance of Caregiver Health

More than the loss of a parent: Potentially traumatic events among orphaned and abandoned children

Child work and labour among orphaned and abandoned children in five low and middle income countries

Prevalence and predictors of HIV-related stigma among institutional- and community-based caregivers of orphans and vulnerable children living in five less-wealthy countries

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

A conceptual framework for the targeting and evaluation of UNICEF-supported pro-equity programmes

A Brief Assessment of Learning for Orphaned and Abandoned Children in Low and Middle Income Countries

Malawi Orphans and Vulnerable Children Evaluation (MOVE)

Cambodia Orphan Project Evaluation (COPE)

Positive Outcomes for Orphans (POFO): Longitudinal study of orphaned and abandoned children (OAC) from ages 6-12 to ages 15-21 living in 6 diverse settings

Child transitions from residential facilities to other communities: predictors of child wellbeing

 Pathways to health and well-being: social networks of orphans and abandoned youth

News articles:

Duke study recently released finds orphans in need of protection

Study finds orphanages are viable option for some children

Protective mental health services critical for orphans worldwide

DGHI study finds child labour is prevalent among orphans

Study finds less reported HIV-related stigma against orphans in institutional care

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