title: Prevalence and Incidence of Traumatic Experiences Among Orphans in Institutional and Family-Based Settings in 5 Low- and Middle-Income Countries: A Longitudinal Study.
abstract: BACKGROUND
  Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings.
  
  
  METHODS
  The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10-13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site.
  
  
  RESULTS
  Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]).
  
  
  CONCLUSIONS
  Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.
authors.affiliation: University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA clgray@email.unc.edu.
authors.forename: Christine L
authors.initials: CL
authors.lastname: Gray
authors.affiliation: University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pence
authors.affiliation: Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA.
authors.forename: Jan
authors.initials: J
authors.lastname: Ostermann
authors.affiliation: Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Whetten
authors.affiliation: Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA Duke University, Center for Child and Family Health, Durham, NC, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: O'Donnell
authors.affiliation: Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA Duke University, Division of Infectious Diseases and International Health, Department of Medicine, Durham, NC, USA.
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Thielman
authors.affiliation: Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA Duke University, Terry Sanford Institute of Public Policy, Durham, NC, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Whetten
mesh_terms: D000293:Adolescent; D000349:Africa / Q000453:epidemiology; D001208:Asia / Q000453:epidemiology; D002648:Child; D002649:Child Abuse / Q000523:psychology / Q000706:statistics & numerical data*; D002674:Child, Institutionalized / Q000523:psychology* / Q000706:statistics & numerical data; D054540:Child, Orphaned / Q000523:psychology* / Q000706:statistics & numerical data; D016000:Cluster Analysis; D003906:Developing Countries; D005190:Family; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008016:Life Change Events; D008137:Longitudinal Studies; D008297:Male; D019372:Orphanages / Q000706:statistics & numerical data; D011203:Poverty; D015995:Prevalence; D013315:Stress, Psychological / Q000453:epidemiology* / Q000523:psychology*