Models of care for orphaned and separated children and upholding children's rights: cross-sectional evidence from western Kenya

Resilience and associated factors in orphaned and separated adolescents in Kenya: Understanding the relationship with care environment and HIV risks

Orphans are at higher risk of HIV infection and several important HIV risk factors than non-orphans; however, this may be due to a combination of related social, psychological, and economic factors, as well as care environment, rather than orphan status alone. Understanding these complex relationships may aid policy makers in supporting evidence-based, cost-effective programming for this vulnerable population. This longitudinal study uses a causal effect model to examine, through decomposition, the relationship between care environment and HIV risk factors in orphaned and separated adolescents and youths (OSAY) in Uasin Gishu County, Kenya; considering resilience, social, peer, or family support, volunteering, or having one's material needs met as potential mediators. We analysed survey responses from 1105 OSAY age 10-26 living in Charitable Children's Institutions (CCI) (orphanages) and family-based care settings (FBS). Follow-up time was 7-36 months. Care in CCIs (vs. FBS) was associated with a decreased likelihood of engaging in forced, exchange, and consensual sex. Excess relative risks (ERR) attributable to the indirect pathway, mediation, or interaction were not significant in any model. Care environment was not statistically associated with differences in substance use. Our findings support the direct, unmediated, association between institutional care and HIV risk factors.

Global priority for the care of orphans and other vulnerable children: transcending problem definition challenges

BACKGROUND

Tens of millions of children lack adequate care, many having been separated from or lost one or both parents. Despite the problem's severity and its impact on a child's lifelong health and wellbeing, the care of vulnerable children-which includes strengthening the care of children within families, preventing unnecessary family separation, and ensuring quality care alternatives when reunification with the biological parents is not possible or appropriate-is a low global priority. This analysis investigates factors shaping the inadequate global prioritization of the care of vulnerable children. Specifically, the analysis focuses on factors internal to the global policy community addressing children's care, including how they understand, govern, and communicate the problem.

METHODS

Drawing on agenda setting scholarship, we triangulated among several sources of data, including 32 interviews with experts, as well as documents including peer-reviewed literature and organizational reports. We undertook a thematic analysis of the data, using these to create a historical narrative on efforts to address children's care, and specifically childcare reform.

RESULTS

Divisive disagreements on the definition and legitimacy of deinstitutionalization-a care reform strategy that replaces institution-based care with family-based care-may be hindering priority for children's care. Multiple factors have shaped these disagreements: a contradictory evidence base on the scope of the problem and solutions, divergent experiences between former Soviet bloc and other countries, socio-cultural and legal challenges in introducing formal alternative care arrangements, commercial interests that perpetuate support for residential facilities, as well as the sometimes conflicting views of impacted children, families, and the disability community. These disagreements have led to considerable governance and positioning difficulties, which have complicated efforts to coordinate initiatives, precluded the emergence of leadership that proponents universally trust, hampered the engagement of potential allies, and challenged efforts to secure funding and convince policymakers to act.

CONCLUSION

In order to potentially become a more potent force for advancing global priority, children's care proponents within international organizations, donor agencies, and non-governmental agencies working across countries will need to better manage their disagreements around deinstitutionalization as a care reform strategy.

Youth Who Have Lived in Alternative Care in Nigeria, Zambia, and Zimbabwe: Mental Health and Violence Outcomes in Nationally Representative Data

Objective

We explore whether having previously lived in alternative care (foster, kinship, and/or residential care) is linked to sexual risk-taking, mental health, and experiencing violence in Nigerian, Zambian, and Zimbabwean youth ages 13-17 living in households with or without their biological parents, and assess the utility and limitations of existing data.

Method

This study is a secondary analysis of nationally-representative Violence Against Children Surveys (N=6,405). Logistic regressions examined the effect of alternative care experience on the odds of poor outcomes, controlling for covariates including parental care status, orphanhood, and household assets.

Results

In both bivariate and multivariate analyses, having lived in alternative care in the last five years was associated with lowered odds mental distress (OR=0.25, 95% CI: [0.10, 0.61], p=.002), and higher odds of sexual risk taking (OR=1.70, 95% CI: [1.11, 2.59], p=.014), caregiver physical abuse (OR=1.81, 95% CI: [1.30, 2.50], p<.001), caregiver emotional abuse (OR=1.75, 95% CI: [1.20, 2.54], p=.004), and peer violence (OR=1.57, 95% CI: [1.09, 2.26], p=.015). It was not associated with suicidality, self harm, or sexual assault after controlling for covariates.

Conclusion

Youth who have lived in alternative care in the last five years may benefit from programs that address violence, self-harm, and sexual risk taking behavior, even if they are now in families. To better understand children outside parental care, national data collection efforts should distinguish between residential and family-based care.

HIV Incidence and Death Among Orphaned and Nonorphaned Children and Adolescents Living in Family-Based Settings in Western Kenya: A Prospective Cohort Analysis

OBJECTIVE

To compare the incidence of HIV, death, and abuse among orphaned children to nonorphaned children living in households caring for orphaned children in Western Kenya.

STUDY DESIGN

A random sample was taken of 300 households caring for at least one orphaned child in Uasin Gishu County, Kenya. All orphaned and nonorphaned children in each selected household were enrolled in a prospective cohort study between 2010 and 2013. A total of 1488 children (487 double orphans, 743 single orphans, and 258 nonorphans) were followed up annually until 2019. Survival analysis was used to estimate hazard ratios and 95% confidence intervals (CIs) of the association between the number of parents the child had lost (none, 1, or 2), and HIV incidence, death, combined HIV incidence or death, and incident abuse.

RESULTS

Among 1488 children enrolled, 52% of participants were females, 23 were HIV positive, and the median age was 10.4 years. Over the course of the study, 16 orphaned children died and 11 acquired HIV. No deaths or incident HIV infections were observed among the nonorphaned children. Among children who were HIV negative at enrollment, loss of a parent was strongly associated with incident HIV (adjusted hazard ratio: 2.21 per parent lost, 95% CI: 1.03-4.73) and HIV or death (adjusted hazard ratio: 2.46 per parent lost, 95% CI: 1.37-4.42). There were no significant associations between orphan level and abuse.

CONCLUSIONS

In similar households, orphaned children experience a higher risk of HIV and death than nonorphaned children. Both orphaned children and the families caring for them need additional support to prevent adverse health outcomes.

Sexual knowledge, risk behavior, and access to reproductive health services among orphaned adolescents in Southwest Nigeria: implications for institutionalized care

Introduction

An orphan has been defined as a child under 18 years of age who has lost one or both parents to any cause. It has been reported that for every 10 Nigerian children, 1 is likely to be an orphan. Adolescents are faced with a serious challenge in meeting their reproductive health need, which oftentimes becomes overwhelming especially when they are orphaned.

Objectives

We compared institutionalized and non-institutionalized orphaned adolescents for their knowledge of sexuality, risky sexual practice, and access to reproductive health services.

Methods

The study adopted a cross-sectional descriptive study design conducted via structured, pretested, and interviewer-administered questionnaires among 205 orphaned adolescents (140 institutionalized and 65 non-institutionalized). Data were analyzed using the Statistical Product and Service Solution (SPSS version 25.0) and summarized using frequency, mean and percentages, and inferential statistics. All analyses were done at a 95% confidence interval and at a p < 0.05 level of significance.

Results

The knowledge levels of a majority of non-institutionalized respondents (73.8%) were good when compared with those in institutions (56.4%) (χ² = 5.713, p = 0.017). Institutionalized orphans displayed better sexual behavior (80.7%) than non-institutionalized respondents (64.6%) (χ² = 6.239, p = 0.011). Access to reproductive health services was found to be slightly higher among institutionalized respondents (66.4%) than among their non-institutionalized counterparts (64.6%).

Conclusion

Institutionalized and non-institutionalized orphans differed in terms of their knowledge of sexuality, sexual behavior, and risky practices, including access to reproductive health services. This study demonstrated the effectiveness of institutionalized care of orphans toward improved access to reproductive health services and good sexual practices. In the light of this, the government and relevant stakeholders should advocate the need for providing better sexuality education and understanding, make sure that access barriers for orphans are removed and orphans utilize the facilities for reproductive health that are available, and also make sure that adolescent health policies are implemented effectively.

Prevalence, incidence and chronicity of child abuse among orphaned, separated, and street-connected children and adolescents in western Kenya: What is the impact of care environment?

BACKGROUND

The effect of different types of care environment on orphaned and separated children and adolescents' (OSCA) experiences of abuse in sub-Saharan Africa is uncertain.

OBJECTIVE

Our two primary objectives were 1) to compare recent child abuse (physical, emotional, and sexual) between OSCA living in institutional environments and those in family-based care; and 2) to understand how recent child abuse among street-connected children and youth compared to these other vulnerable youth populations.

PARTICIPANTS AND SETTING

This project followed a cohort of OSCA in Uasin Gishu County, Kenya (2009-2019). This analysis includes 2393 participants aged 18 years and below, 1017 from institutional environments, 1227 from family-based care, and 95 street-connected participants.

METHODS

The primary outcome of interest was recent abuse. Multiple logistic regression was used to estimate the odds of recent abuse at baseline, follow-up, and chronically for each abuse domain and adjusted odds ratios (AOR) between care environments, controlling for multiple factors.

RESULTS

In total, 47 % of OSCA reported ever experiencing any kind of recent abuse at baseline and 54 % in follow-up. Compared to those in family-based care, street-connected participants had a much higher reported prevalence of all types of recent abuse at baseline (AOR: 5.01, 95 % CI: 2.89, 9.35), in follow-up (AOR: 5.22, 95 % CI: 2.41, 13.98), and over time (AOR: 3.44, 95 % CI: 1.93, 6.45). OSCA in institutional care were no more likely than those in family-based care of reporting any recent abuse at baseline (AOR: 0.85 95 % CI: 0.59-1.17) or incident abuse at follow-up (AOR: 0.91, 95 % CI: 0.61-1.47).

CONCLUSION

OSCA, irrespective of care environment, reported high levels of recent physical, emotional, and sexual abuse. Street-connected participants had the highest prevalence of all kinds of abuse. OSCA living in institutional care did not experience more child abuse than those living in family-based care.

Cost Utility of Supporting Family-Based Care to Prevent HIV and Deaths among Orphaned and Separated Children in East Africa: A Markov Model-Based Simulation

Purpose. Strengthening family-based care is a key policy response to the more than 15 million orphaned and separated children who have lost 1 or both parents in sub-Saharan Africa. This analysis estimated the cost-effectiveness of family-based care environments for preventing HIV and death in this population. Design. We developed a time-homogeneous Markov model to simulate the incremental cost per disability-adjusted life year (DALY) averted by supporting family-based environments caring for orphaned and separated children in western Kenya. Model parameters were based on data from the longitudinal OSCAR's Health and Well-Being Project and published literature. We used a societal perspective, annual cycle length, and 3% discount rate. Incremental cost-effectiveness ratios were simulated over 5- to 15-y horizons, comparing family-based settings to street-based "self-care." Parameter uncertainty was addressed via deterministic and probabilistic sensitivity analyses. Results. Under base-case assumptions, family-based environments prevented 422 HIV infections and 298 deaths in a simulated cohort of 1,000 individuals over 10 y. Compared with street-based self-care, family-based care had an incremental cost of $2,528 per DALY averted (95% confidence interval [CI]: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413). The probability of family-based care being highly cost-effective was >80% at a willingness-to-pay (WTP) threshold of $2,250/DALY averted. Households receiving government cash transfers had minimally higher cost-effectiveness ratios than households without cash transfers but were still cost-effective at a WTP threshold of twice Kenya's GDP per capita. Conclusions. Compared with the status quo of street-based self-care, family-based environments offer a cost-effective approach for preventing HIV and death among orphaned children in lower-middle income countries. Decision makers should consider increasing resources to these environments in tandem with social protection programs.

Highlights

UNICEF and more than 200 other international organizations endorsed efforts to redirect services toward family-based care as part of the 2019 UN Resolution on the Rights of the Child; yet this study is one of the first to quantify the cost-effectiveness of family-based care environments serving some of the world's most vulnerable children.This health economic modeling analysis found that family-based environments would prevent 422 HIV infections and 298 deaths in a cohort of 1,000 orphaned and separated children over a 10-y time horizon.Compared with street-based "self-care," family-based care resulted in an incremental cost of $2,528 per DALY averted (95% CI: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413) after 10 y.Annual per-child expenditures for children living in family-based care environments in sub-Saharan Africa could potentially be increased by at least 25% and remain highly cost-effective.

Measuring Urban Sustainability over Time at National and Regional Scale for Addressing United Nations Sustainable Development Goal (SDG) 11: Iran and Tehran as Case Studies

It is evident that relations between political conditions and community development have become sophisticated in recent years. More people now live in urbanized areas, and this ongoing urbanization has various ramifications. Many countries are facing swift urban transformation which alters their regional development patterns. Urban sprawl, migration and rural depopulation, regional inequalities, increasing urban poverty, and social injustice are some of these emerging problems. Assessing regional development for identifying the aforementioned predicaments is really imperative and related to the United Nations Sustainable Development Goal (SDG) 11. However, there are limited studies that focus on the assessment of regional sustainable development at both national and regional scales, simultaneously. Thus, this study aims to fill the gap by developing a robust method that can assess and compare the level of sustainability in various regions and at varying scales. This helps to identify areas where urgent prevention or mitigation strategies and action plans are required. In this study, we strived to evaluate Iran’s regions and Tehran’s provinces based on sustainability indicators. To end this, the authors use factor analysis and F’ANP model in both assessments. The results of the study show that Tehran Province was the most developed province, and its F’ANP result was 2.006. Tehran is 10% more sustainable than the third region in the country which is Khorasan Razavi. Isfahan and Khorasan Razavi provinces were in the next in rank with scores of 1.984 and 1.8, respectively. At the bottom of the list, the northern Khorasan, Ilam, and Kohkiloye-Boyerahmad provinces were in the lowest ranked in terms of access to sustainability indices. It is patently obvious that Iran suffers from uneven development, and the majority of border provinces have moderate or bad situations. This uneven development also intensifies migration to Tehran, which already has one-sixth of Iran’s population which has led todeteriorating social inequity and environmental injustice, nationally. The results of the regional assessment of Tehran also show that there is uneven development in Tehran Province. Tehran County is twice as good and sustainable as 68 percent of the counties in this region. The F’ANP result for Tehran County was 0.580, and it has been ranked first over a period due to the exceptional number of facilities in this region. Tehran County became 20% more sustainable during this decade. After Tehran, Firoozkoh and Damavand counties were in the next ranks with scores of 0.389 and 0.343, respectively. Qarchak, Ghods, and Baharestan counties were the weakest based on the sustainability indices, and their F’ANP results were below 0.2.

The relationships between resilience, care environment, and social-psychological factors in orphaned and separated adolescents in western Kenya

The relationships between care environment, resilience, and social factors in orphaned and separated adolescents and youths (OSAY) in western Kenya are complex and under-studied. This study examines these relationships through the analysis of survey responses from OSAY living in Charitable Children's Institutes (CCI) and family-based care settings (FBS) in Uasin Gishu County, Kenya. The associations between 1) care environment and resilience (measured using the 14-item Resilience Scale); 2) care environment and factors thought to promote resilience (e.g. social, family, and peer support); and 3) resilience and these same resilience-promoting factors, were examined using multivariable linear and logistic regressions. This cross-sectional study included 1202 OSAY (50.4% female) aged 10-26 (mean=16; SD=3.5). The mean resilience score in CCIs was 71 (95%CI=69-73) vs. 64 (95%CI=62-66) in FBS. OSAY in CCIs had higher resilience (β=7.67; 95%CI=5.26-10.09), social support (β=0.26; 95%CI=0.14-0.37), and peer support (β=0.90; 95%CI=0.64-1.17) than those in FBS. OSAY in CCIs were more likely to volunteer than those in FBS (OR=3.72; 95%CI=1.80-7.68), except in the male subgroup. Family (β=0.42; 95%CI=0.24-0.60), social (β=4.19; 95%CI=2.53-5.85), and peer (β=2.13; 95%CI=1.44-2.83) relationships were positively associated with resilience in all analyses. Volunteering was positively associated with resilience (β=5.85; 95%CI=1.51-10.19). The factor most strongly related to resilience in both fully adjusted models was peer support. This study found a strong relationship between care environment and resilience. Care environment and resilience each independently demonstrated strong relationships with peer support, social support, and participating in volunteer activities. Resilience also had a strong relationship with familial support. These data suggest that resilience can be developed through strategic supports to this vulnerable population.

Effect of care environment on educational attainment among orphaned and separated children and adolescents in Western Kenya

Background

There are approximately 140 million orphaned and separated children (OSCA) around the world. In Kenya, many of these children live with extended family while others live in institutions. Despite evidence that orphans are less likely to be enrolled in school than non-orphans, there is little evidence regarding the role of care environment. This evidence is vital for designing programs and policies that promote access to education for orphans, which is not only their human right but also an important social determinant of health. The purpose of this study was to compare educational attainment among OSCA living in Charitable Children’s Institutions and family-based settings in Uasin Gishu County, Kenya.

Methods

This study analyses follow up data from a cohort of OSCA living in 300 randomly selected households and 17 institutions. We used Poisson regression to estimate the effect of care environment on primary school completion among participants age ≥ 14 as well as full and partial secondary school completion among participants age ≥ 18. Risk ratios and 95% confidence intervals were estimated using a bootstrap method with 1000 replications.

Results

The analysis included 1406 participants (495 from institutions, 911 from family-based settings). At baseline, 50% were female, the average age was 9.5 years, 54% were double orphans, and 3% were HIV-positive. At follow-up, 76% of participants age ≥ 14 had completed primary school and 32% of participants age ≥ 18 had completed secondary school. Children living in institutions were significantly more likely to complete primary school (aRR: 1.18, 95% CI: 1.10–1.28) and at least 1 year of secondary school (aRR: 1.28, 95% CI: 1.18–1.39) than children in family-based settings. Children living in institutions were less likely to have completed all 4 years secondary school (aRR: 0.79, 95% CI: 0.43–1.18) than children in family-based settings.

Conclusion

Children living in institutional environments were more likely to complete primary school and some secondary school than children living in family-based care. Further support is needed for all orphans to improve primary and secondary school completion. Policies that require orphans to leave institution environments upon their eighteenth birthday may be preventing these youth from completing secondary school.

Sexual debut and risk behaviors among orphaned and vulnerable children in Zambia: which protective deficits shape HIV risk?

Orphaned and vulnerable children (OVC) are not only affected by, but also rendered at-risk of, HIV due to overlapping deficits in protective assets, from school to household financial security. Drawing from a protective deficit framework, this study examines correlates of sexual risk - including multiple sexual partnerships, unprotected sex, and age at sexual debut - among OVC aged 13-17 years in Zambia. In May-October 2016, a two-stage stratified random sampling design was used to recruit OVC and their adult caregivers (N = 2,034) in four provinces. OVC-caregiver dyads completed a structured interview addressing household characteristics, protective assets (i.e. finances, schooling, and nutrition), and general health and wellbeing. Associations of factors derived from the multi-component protective deficits framework were examined using multivariable ordered logistic regression, comparing sexually inexperienced OVC to those with a sexual debut and reporting ≥1 sexual behavior(s). A sub-analysis of older (ages 15-17) OVC identified correlates of early (before age 15) and later (at or after age 15) sexual debut using multinomial logistic regression. Among 735 OVC aged 13-17, 14% reported a sexual debut, among whom 14% and 22% reported 2+ past-year partners and non-condom last sex, respectively. Older age (Adjusted Odds Ratio [aOR] = 2.08, 95% Confidence Interval [CI] 1.32-3.27), male sex (aOR = 1.90, CI 1.22-2.96), not having a birth certificate (aOR = 2.05, CI 1.03-4.09), out-of-school status (aOR = 2.63, CI 1.66-4.16), and non-household labor (aOR = 1.84, CI 1.01-3.38) were significantly associated with higher sexual risk. Male sex was the only factor significantly associated with early sexual debut in multivariable analysis. Sexual risk-reduction strategies require age- and sex-specific differentiation and should be prioritized for OVC in financially distressed households.

Association of Care Environment With HIV Incidence and Death Among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya

IMPORTANCE

In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced a proliferation of institutional care. Few studies have investigated the association between care environment and physical health among orphaned and separated youths in sub-Saharan Africa.

OBJECTIVE

To examine the association of care environment with incident HIV and death among orphaned and separated children and adolescents who were living in charitable children's institutions, family-based settings, and street settings in western Kenya over almost 10 years.

DESIGN, SETTING, AND PARTICIPANTS

The Orphaned and Separated Children's Assessments Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and street-connected children from communities within 8 administrative locations, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children's institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019.

EXPOSURES

Care environment (family-based, institutional, or street setting).

MAIN OUTCOMES AND MEASURES

Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death.

RESULTS

Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children's institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55).

CONCLUSIONS AND RELEVANCE

In this study, after adjusting for potential confounders, no association was found between care environment and HIV incidence or death among youths living in institutional vs family-based settings. However, living in a street setting vs a family-based setting was associated with both HIV incidence and death. This study's findings suggest that strengthening of child protection systems and greater investment in evidence-based family support systems that improve child and adolescent health and prevent youth migration to the street are needed for safe and beneficial deinstitutionalization to be implemented at scale.

Intervention Model for Orphan’s Emotional and Behavioral Problems: A Scoping Review

BACKGROUND: As many as, 45% of orphaned children and adolescents living in orphanages experience behavioral and emotional problems. Several literature reviews on the intervention of emotional and behavioral problems in orphan children and adolescents have been widely conducted. However, there is paucity in the reviews of emotional and behavioral problem interventions in the orphan group based on the type of group approach used in published articles. AIM: This study aimed to synthesize the results on the interventions of emotional and behavioral problems in orphan children and adolescents aged 7–20 years who live in institutions or orphanages. METHODS: This research was a scoping review. This review used three databases comprising PubMed, Science Direct, and Wiley Library Online. The inclusion criteria were experimental research designs and cohort studies, published in the 2009–2019, discussed emotional and behavioral problem’s intervention in orphan, and written in English. The exclusion criteria were that the research subjects had severe mental and psychosocial disorders such as autism, mental retardation, and mental disorders. The authors used three categories of keywords; the first keyword and its synonym were “intervention, treatment.” The second keyword focused on behavioral problems, which was “behavioral difficulties,” and the third keyword focuses on population and place, “orphan, institutions orphans, orphanages.” The article selection stage is described in detail in the flow diagram of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The critical appraisal stage used the checklist from Joanna Briggs Institute. RESULTS: Ten articles were found and selected for review. The main emotional and behavioral problems experienced by orphan children and adolescents include depression, anxiety, and low self-esteem, feelings of anger, and trauma. Other problems related, functional disorders, life satisfaction, the probability of suicide, and early (prodromal) symptoms of psychosis, also arise. There were six types of interventions given to overcome emotional and behavioral problems in orphan children and adolescents, but the interventions that are most often given are cognitive therapy, educational support, complementary, and alternative medicine. The approaches in groups that are often used in this review are the support group and the teaching-learning group. The combination of two or more approaches in one intervention can increase the success or effectiveness in overcoming emotional and behavioral problems. CONCLUSIONS: Depression, anxiety, low self-esteem, feeling anger, and trauma are main problems for orphans. To address these emotional and behavior problems, it is necessary to combine several interventions and a combination of group-based approaches.

Maternally Orphaned Children and Intergenerational Concerns Associated With Breast Cancer Deaths Among Women in Sub-Saharan Africa

IMPORTANCE

Low breast cancer survival in sub-Saharan Africa's young population increases the likelihood that breast cancer deaths result in maternal orphans, ie, children (<18 years) losing their mother.

OBJECTIVE

To estimate the number of maternal orphans and their ages for every 100 breast cancer deaths in sub-Saharan African settings during 2014-2019 and to describe family concerns about the orphaned children.

DESIGN, SETTING, AND PARTICIPANTS

Deaths occurring between September 1, 2014, and July 1, 2019, in the African Breast Cancer-Disparities in Outcomes (ABC-DO) were examined in a cohort of women diagnosed with breast cancer during 2014-2017 at major cancer treatment hospitals in Namibia, Nigeria, Uganda, and Zambia. The cohort was actively followed up for vital status via a trimonthly mobile phone call to each woman or her next of kin (typically a partner, husband, or child).

MAIN OUTCOMES AND MEASURES

The number (Poisson counts) and ages of new orphans at the time of maternal death.

RESULTS

This cohort study found that a total of 795 deaths resulted in 964 new maternal orphans, with deaths occurring in women younger than 50 years accounting for 85% of the orphans. For every 100 deaths in women younger than 50 years, there were 210 new orphans (95% CI, 196-225) overall, with country-specific estimates of 189 in Nigerian, 180 in Namibian, 222 in Ugandan, and 247 in Zambian Black women. For every 100 deaths of the women at any age, there were 121 maternal orphans, 17% of whom were younger than 5 years, 32% aged 5 to 9 years, and 51% aged 10 to 17 years at the time of maternal death. In follow-up interviews, families' concerns for children's education and childcare were reported to be exacerbated by the financial expenses associated with cancer treatment.

CONCLUSIONS AND RELEVANCE

This study provides evidence that the number of maternal orphans due to breast cancer exceeds the number of breast cancer deaths among women in sub-Saharan Africa. The intergenerational consequences associated with cancer deaths in sub-Saharan Africa appear to be large and support the need for continued action to improve survival.

Integrated psychosocial, economic strengthening, and clinical service-delivery to improve health and resilience of adolescents living with HIV and their caregivers: Findings from a prospective cohort study in Zambia

BACKGROUND

Children and youth are profoundly impacted groups in Zambia's HIV epidemic. To evaluate delivery of integrated psychosocial, economic strengthening, and clinical services to HIV-affected households through the Zambia Family (ZAMFAM) Project, a prospective cohort study compared socio-economic, psychosocial, and health outcomes among ZAMFAM beneficiaries to non-beneficiaries.

METHODS

In July-October 2017, 544 adolescents living with HIV (ALHIV) aged 5-17 years and their adult caregivers were recruited from Central (ZAMFAM implementation sites) and Eastern (non-intervention sites) Provinces. Structured interviews at baseline and one-year follow-up assessed household characteristics, socio-economic wellbeing, and health service utilization. Poisson regression with generalized estimating equations measured one-year changes in key health and socio-economic indicators, comparing ZAMFAM beneficiaries to non-beneficiaries.

RESULTS

Overall, 494 households completed two rounds of assessment (retention rate: 91%) Among ALHIV, improvements in current antiretroviral therapy use over time (Adjusted Prevalence Rate Ratio [aPRR] = 1.06, 95% Confidence Interval [95% CI]: 1.01-1.11) and reductions in non-household labor (aPRR = 0.44, 95% CI: 0.20-0.99) were significantly larger among ZAMFAM beneficiaries than non-beneficiaries. For caregivers, receiving ZAMFAM services was associated with significant reductions in HIV-related stigma (aPRR = 0.49, 95% CI: 0.28-0.88) and perceived negative community attitudes towards HIV (aPRR = 0.77, 95% CI: 0.62-0.96). Improvements in caregiver capacity to pay for unexpected (aPRR = 1.54, 95% CI: 1.17-2.04) and food-related expenses (aPRR = 1.48, 95% CI: 1.16-1.90), as well as shared decision-making authority in household spending (aPRR = 1.41, 95% CI: 1.04-1.93) and self-reported good or very good health status (aPRR = 1.46, 95% CI: 1.14-1.87), were also significantly larger among ZAMFAM beneficiaries.

CONCLUSIONS

Significant improvements in caregivers' financial capacity were observed among households receiving ZAMFAM services, with few changes in health or wellbeing among ALHIV. Integrated service-delivery approaches like ZAMFAM may yield observable socio-economic improvements in the short-term. Strengthening community-based delivery of psychosocial and health support to ALHIV is encouraged.

Factors affecting the psychosocial well-being of orphan and separated children in five low- and middle-income countries: Which is more important, quality of care or care setting?

As millions of children continue to live without parental care in under-resourced societies in low- and middle-income countries (LMICs), it is important for policymakers and practitioners to understand the specific characteristics within different care settings and the extent to which they are associated with outcomes of orphan and separated children (OSC). This study was designed to (1) examine if the psychosocial well-being of OSC in under-resourced societies in LMICs is more dependent on the availability of certain components of quality of care rather than the care setting itself (i.e. the residential care-based or community family-based setting), and (2) identify the relative significance of certain components of quality of care that are associated with a child's psychosocial well-being across different OSC care settings. This study drew from 36-month follow-up data from the Positive Outcomes for Orphans (POFO) Study and used a sample population of 2,013 (923 institution- and 1,090 community-based) OSC among six diverse study sites across five LMICs: Cambodia, India (Hyderabad and Nagaland), Kenya, Tanzania, and Ethiopia. Analyses showed that all four components of quality of care significantly predicted child psychosocial well-being. Child psychosocial well-being across "high" and "low" levels of quality of care showed negligible differences between residential- and community-based care settings, suggesting the important factor in child well-being is quality of care rather than setting of care. Practical and policy implications and future research are discussed.

A systematic scoping review of hygiene behaviors and environmental health conditions in institutional care settings for orphaned and abandoned children

BACKGROUND

Adequate hygiene behaviors and environmental health conditions are fundamental to children's health, development, and well-being. They are especially important in institutional care settings for orphaned and abandoned children, a particularly vulnerable population whose basic needs are often not met.

OBJECTIVES

We systematically reviewed the evidence about hygiene behaviors and environmental health conditions in institutional care settings for children and associated health outcomes; interventions to improve these behaviors, conditions, and outcomes; and obstacles to improvement.

METHODS

PubMed, Web of Science, Scopus, and EBSCOhost were searched for studies in the peer-reviewed and grey literature. Studies were included if they reported primary data on one or more environmental health condition or hygiene behavior in an institutional care setting for orphaned and abandoned children.

RESULTS

Forty-five publications reporting on over 500 institutions in 29 countries were included. The most documented concern was poor personal hygiene behaviors followed by inadequate water and sanitation infrastructure and overcrowding. Protozoan, helminthic, viral infections, and diarrheal illness among institutionalized children were the most commonly documented associated health outcomes.

DISCUSSION

More studies documented the status of hygiene and environmental health in children's institutions than interventions to improve behaviors and conditions. Insufficient finances and expertise or involvement of caregivers are reported barriers to implementing improvements in children's institutions. The development of guidelines for essential environmental health standards in orphanages, monitoring of facility conditions, accountability for facility deficiencies, and implementation research to identify improvement opportunities would contribute to and promote the health and development of orphaned and abandoned children worldwide.

Language Outcomes in Adults with a History of Institutionalization: Behavioral and Neurophysiological Characterization

Impoverished early care environments are associated with developmental deficits in children raised in institutional settings. Despite the accumulation of evidence regarding deficits in general cognitive functioning in this population, less is known about the impact of institutionalization on language development at the level of brain and behavior. We examined language outcomes in young adults and adolescents raised in institutions (n = 23) as compared to their socioeconomic status and age peers raised in biological families (n = 24) using a behavioral language assessment and linguistic event-related potentials (ERPs). Controlling for intelligence, adults with a history of institutionalization demonstrated deficits in lexical and grammatical development and spelling. Analyses of ERP data revealed significant group differences in the dynamic processing of linguistic stimuli. Adults with a history of institutionalization displayed reduced neural sensitivity to violations of word expectancy, leading to reduced condition effects for temporo-spatial factors that tentatively corresponded to the N200, P300/N400, and phonological mismatch negativity. The results suggest that language is a vulnerable domain in adults with a history of institutionalization, the deficits in which are not explained by general developmental delays, and point to the pivotal role of early linguistic environment in the development of the neural networks involved in language processing.

Unconditional government cash transfers in support of orphaned and vulnerable adolescents in western Kenya: Is there an association with psychological wellbeing?

Background

Orphaned and vulnerable adolescents (OVA) in sub-Saharan Africa are at greater risk for adverse psychological outcomes compared with their non-OVA counterparts. Social interventions that provide cash transfers (CTs) have been shown to improve health outcomes among young people, but little is known about their impact on the psychological wellbeing of OVA.

Objective

Among OVA in western Kenya, we assessed the association between living in a household that received monthly unconditional government CTs and psychological wellbeing.

Methods

We examined the likelihood of depression, anxiety, post-traumatic stress symptoms (PTSS) and positive future outlook among 655 OVA aged between 10 and 18 years who lived in 300 randomly selected households in western Kenya that either received or did not receive unconditional monthly CTs.

Results

The mean age was 14.0 (SD 2.4) years and 329 (50.2%) of the participants were female while 190 (29.0%) were double orphans whose biological parents were both deceased. After adjusting for socio-demographic, caregiver, and household characteristics and accounting for potential effects of participant clustering by sub-location of residence, OVA living in CT households were more likely to have a positive future outlook (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.08, 1.99), less likely to be anxious (OR 0.57, 95% CI 0.42, 0.78), and less likely to have symptoms of post-traumatic stress (OR 0.50, 95% CI 0.29, 0.89). We did not find statistically significant differences in odds of depression by CT group.

Conclusion

OVA in CT households reported better psychological wellbeing compared to those in households not receiving CTs. CT interventions may be effective for improving psychological wellbeing among vulnerable adolescents in socioeconomically deprived households.

Sexual Behavior Among Orphaned Adolescents in Western Kenya: A Comparison of Institutional- and Family-Based Care Settings

PURPOSE

This study sought to assess whether risky sexual behaviors and sexual exploitation of orphaned adolescents differed between family-based and institutional care environments in Uasin Gishu County, Kenya.

METHODS

We analyzed baseline data from a cohort of orphaned adolescents aged 10-18 years living in 300 randomly selected households and 19 charitable children's institutions. The primary outcomes were having ever had consensual sex, number of sex partners, transactional sex, and forced sex. Multivariate logistic regression compared these between participants in institutional care and family-based care while adjusting for age, sex, orphan status, importance of religion, caregiver support and supervision, school attendance, and alcohol and drug use.

RESULTS

This analysis included 1,365 participants aged ≥10 years: 712 (52%) living in institutional environments and 653 (48%) in family-based care. Participants in institutional care were significantly less likely to report engaging in transactional sex (adjusted odds ratio, .46; 95% confidence interval, .3-.72) or to have experienced forced sex (adjusted odds ratio, .57; 95% confidence interval, .38-.88) when controlling for age, sex, and orphan status. These associations remained when adjusting for additional variables.

CONCLUSIONS

Orphaned adolescents living in family-based care in Uasin Gishu, Kenya, may be at increased risk of transactional sex and sexual violence compared to those in institutional care. Institutional care may reduce vulnerabilities through the provision of basic material needs and adequate standards of living that influence adolescents' sexual risk-taking behaviors. The use of single items to assess outcomes and nonexplicit definition of sex suggest the findings should be interpreted with caution.

National estimation of children in residential care institutions in Cambodia: a modelling study

OBJECTIVES

The primary objective of this study was to collect baseline data on the number of children living in residential care institutions in Cambodia. The secondary objective was to describe the characteristics of the children (eg, age, sex, duration of stay, education and health). The data were intended to guide recent efforts by the Government of Cambodia to reduce the number of children living in residential care institutions and increase the number of children growing up in supportive family environments.

SETTING

Data were collected in Cambodia across 24 sites at the commune level. Communes-administrative divisions roughly equivalent to counties-were selected by the National Institute of Statistics using a two-stage sampling method.

DESIGN

Government lists and key informant interviews were used to construct a complete roster of institutions across the 24 communes. All identified institutions were visited to count the number of children and gather data on their basic characteristics. The rate of children in residential care in the selected communes was calculated as a percentage of total population using a Poisson model. This rate was applied to all districts in Cambodia with at least one reported residential care institution.

PARTICIPANTS

A total of 3588 children were counted across 122 institutions. A child living in a residential care institution was defined as anyone under the age of 18 years who was sleeping in the institution for at least four nights per week during the data collection period.

RESULTS

There are an estimated 48 775 children living in residential care institutions in Cambodia. The vast majority of children have a living parent and are school-aged. More than half are between 13 and 17 years of age.

CONCLUSIONS

Nearly 1 of every 100 children in Cambodia is living in residential care. This raises substantial concerns for child health, protection and national development.

Institutional Care of Children in Low- and Middle-Income Settings: Challenging the Conventional Wisdom of Oliver Twist

Whether institutions or extended families are better suited to care for orphans depends on the specific circumstances. Reported rates of traumatic experiences among orphans and vulnerable children are high in both institutions and extended families; improving the quality of care for such children should be the paramount priority in all settings.

Continuing with "…a heavy heart" - consequences of maternal death in rural Kenya

BACKGROUND

This study analyzes the consequences of maternal death to households in Western Kenya, specifically, neonatal and infant survival, childcare and schooling, disruption of daily household activities, the emotional burden on household members, and coping mechanisms.

METHODS

The study is a combination of qualitative analysis with matched and unmatched quantitative analysis using surveillance and survey data. Between September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy that led to the death; schooling experiences of surviving school-age children; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions. Quantitative data on neonatal and infant survival from a demographic surveillance system in the study area were also used. Descriptive and bivariate analyses were conducted with the quantitative data, and qualitative data were analyzed through text analysis using NVivo.

RESULTS

More than three-quarters of deceased women performed most household tasks when healthy. After the maternal death, the responsibility for these tasks fell primarily on the deceased's husbands, mothers, and mothers-in-law. Two-thirds of the individuals from households that suffered a maternal death had to shift into another household. Most children had to move away, mostly to their grandmother's home. About 37% of live births to women who died of maternal causes survived till age 1 year, compared to 65% of live births to a matched sample of women who died of non-maternal causes and 93% of live births to surviving women. Older, surviving children missed school or did not have enough time for schoolwork, because of increased housework or because the loss of household income due to the maternal death meant school fees could not be paid. Respondents expressed grief, frustration, anger and a sense of loss. Generous family and community support during the funeral and mourning periods was followed by little support thereafter.

CONCLUSION

The detrimental consequences of a maternal death ripple out from the woman's spouse and children to the entire household, and across generations.

The government of Kenya cash transfer for orphaned and vulnerable children: cross-sectional comparison of household and individual characteristics of those with and without

Background

The ‘Cash Transfer to Orphans and Vulnerable Children’ (CT-OVC) in Kenya is a government-supported program intended to provide regular and predictable cash transfers (CT) to poor households taking care of OVC. CT programs can be an effective means of alleviating poverty and facilitating the attainment of an adequate standard of living for people’s health and well-being and other international human rights. The objective of this analysis was to compare the household socioeconomic status, school enrolment, nutritional status, and future outlook of orphaned and separated children receiving the CT compared to those not receiving a CT.

Methods

This project analyzes baseline data from a cohort of orphaned and separated children aged <19 years and non-orphaned children living in 300 randomly selected households (HH) in 8 Locations of Uasin Gishu County, Kenya. Baseline data were analyzed using multivariable logistic and Poisson regression comparing children in CT-HH vs. non-CT HH. Odds ratios are adjusted (AOR) with 95% confidence intervals (CI) for guardian age and sex, child age and sex, and intra-HH correlation.

Results

Included in this analysis were data from 1481 children and adolescents in 300 HH (503 participants in CT, 978 in non-CT households). Overall there were 922 (62.3%) single orphans, 324 (21.9%) double orphans, and 210 (14.2%) participants had both parents alive and were living with them. Participants in CT-HH were less likely to have ≥2 pairs of clothes compared to non-CT HH (AOR: 0.32, 95% CI: 0.16-0.63). Those in CT HH were less likely to have missed any days of school in the preceding month (AOR: 0.62, 95% CI: 0.42-0.94) and those aged <1-18 years in CT-HH were less likely to have height stunting for their age (AOR: 0.65, 95% CI: 0.47-0.89). Participants aged at least 10 years in CT-HH were more likely to have a positive future outlook (AOR: 1.72, 95% CI: 1.12-2.65).

Conclusions

Children and adolescents in households receiving the CT-OVC appear to have better nutritional status, school attendance, and optimism about the future, compared to those in households not receiving the CT, in spite of some evidence of continued material deprivation. Consideration should be given to expanding the program further.

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

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.