Three-year change in the wellbeing of orphaned and separated children in institutional and family-based care settings in five low- and middle-income countries

Abstract

Background: 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.

Methods: A 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.

Findings: At 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.

Interpretation: These 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.

Figure 1. Distribution of child wellbeing measures at baseline and follow-up, by care setting type (Institution-based vs. family-based).

Blue bars are dot plots of the wellbeing measures of individual children at baseline and follow-up, respectively. Each child is represented by one dot.

Figure 2. Changes in wellbeing of orphaned and separated children over 3 years, at the individual level and the institution or community cluster level.

Sample size: Height for age – 252 community clusters, 1231 children; 73 institutions, 916 children. BMI for age – 247 community clusters, 1215 children; 73 institutions, 928 children. Total difficulties score, caregiver report – 245 community clusters, 1210 children; 69 institutions, 866 children. Total difficulties score, self-report – 38 community clusters, 326 children; 36 institutions, 221 children. Cognition (K-ABC II) – 256 community clusters, 1284 children; 73 institutions, 958 children. California Verbal Learning Test – 253 community clusters, 1268 children; 73 institutions, 944 children. The number of observations for self-reported total difficulties score is lower because only children at least 11 years old were asked for self-report. Numbers of observations vary across outcomes because of missing baseline or follow-up data (children) and because mean changes were only calculated for community clusters and institutions with at least 3 children with a change measure.