title: 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.
abstract: BACKGROUND
  Leaders are struggling to care for the estimated 143,000,000 orphans and millions more abandoned children worldwide. Global policy makers are advocating that institution-living orphans and abandoned children (OAC) be moved as quickly as possible to a residential family setting and that institutional care be used as a last resort. This analysis tests the hypothesis that institutional care for OAC aged 6-12 is associated with worse health and wellbeing than community residential care using conservative two-tail tests.
  
  
  METHODS
  The Positive Outcomes for Orphans (POFO) study employed two-stage random sampling survey methodology in 6 sites across 5 countries to identify 1,357 institution-living and 1,480 community-living OAC ages 6-12, 658 of whom were double-orphans or abandoned by both biological parents. Survey analytic techniques were used to compare cognitive functioning, emotion, behavior, physical health, and growth. Linear mixed-effects models were used to estimate the proportion of variability in child outcomes attributable to the study site, care setting, and child levels and institutional versus community care settings. Conservative analyses limited the community living children to double-orphans or abandoned children.
  
  
  RESULTS
  Health, emotional and cognitive functioning, and physical growth were no worse for institution-living than community-living OAC, and generally better than for community-living OAC cared for by persons other than a biological parent. Differences between study sites explained 2-23% of the total variability in child outcomes, while differences between care settings within sites explained 8-21%. Differences among children within care settings explained 64-87%. After adjusting for sites, age, and gender, institution vs. community-living explained only 0.3-7% of the variability in child outcomes.
  
  
  CONCLUSIONS
  This study does not support the hypothesis that institutional care is systematically associated with poorer wellbeing than community care for OAC aged 6-12 in those countries facing the greatest OAC burden. Much greater variability among children within care settings was observed than among care settings type. Methodologically rigorous studies must be conducted in those countries facing the new OAC epidemic in order to understand which characteristics of care promote child wellbeing. Such characteristics may transcend the structural definitions of institutions or family homes.
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America. katewhetten@gmail.com
authors.forename: Kathryn
authors.initials: K
authors.lastname: Whetten
authors.forename: Jan
authors.initials: J
authors.lastname: Ostermann
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Whetten
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pence
authors.forename: Karen
authors.initials: K
authors.lastname: O'Donnell
authors.forename: Lynne C
authors.initials: LC
authors.lastname: Messer
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Thielman
mesh_terms: D017028:Caregivers; D002648:Child; D002669:Child Welfare / Q000523:psychology*; D002670:Child, Abandoned / Q000523:psychology*; D002674:Child, Institutionalized / Q000523:psychology*; D054540:Child, Orphaned / Q000523:psychology*; D003906:Developing Countries; D005260:Female; D005581:Foster Home Care; D006801:Humans; D008297:Male; D012111:Residence Characteristics