title: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America; Terry Sanford Institute of Public Policy, Duke University, Durham, North Carolina, United States of America.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Whetten
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
authors.forename: Jan
authors.initials: J
authors.lastname: Ostermann
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America; Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pence
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Whetten
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America; School of Community Health, College of Urban and Public Affairs, Portland State University, Portland, Oregon, United States of America.
authors.forename: Lynne C
authors.initials: LC
authors.lastname: Messer
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
authors.forename: Sumedha
authors.initials: S
authors.lastname: Ariely
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America; Departments of Psychiatry and Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America; Center for Child and Family Health, Duke University, Durham, North Carolina, United States of America.
authors.forename: Karen
authors.initials: K
authors.lastname: O'Donnell
authors.affiliation: ACE Africa, Bungoma, Kenya.
authors.forename: Augustine I
authors.initials: AI
authors.lastname: Wasonga
authors.affiliation: Homeland, Battambang, Cambodia.
authors.forename: Vanroth
authors.initials: V
authors.lastname: Vann
authors.affiliation: TAWREF, Moshi, Tanzania.
authors.forename: Dafrosa
authors.initials: D
authors.lastname: Itemba
authors.affiliation: Stand for Vulnerable Organization, Addis Ababa, Ethiopia.
authors.forename: Misganaw
authors.initials: M
authors.lastname: Eticha
authors.affiliation: Sahara House, Delhi, India.
authors.forename: Ira
authors.initials: I
authors.lastname: Madan
authors.affiliation: Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America; Department of Medicine, Division of Infectious Diseases and International Health, Duke University, Durham, North Carolina, United States of America.
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Thielman
mesh_terms: D000300:Adoption / Q000523:psychology*; D017028:Caregivers / Q000523:psychology; D002648:Child; D002657:Child Development / Q000502:physiology*; D002669:Child Welfare / Q000941:ethics* / Q000523:psychology; D054540:Child, Orphaned / Q000193:education / Q000523:psychology*; D003625:Data Collection; D003906:Developing Countries; D005260:Female; D005500:Follow-Up Studies; D006304:Health Status; D006801:Humans; D007182:Income; D008297:Male; D019372:Orphanages / Q000941:ethics*; D010549:Personal Satisfaction; D011788:Quality of Life