In 2006, the POFO study began following orphaned and abandoned children (OAC) ages 6 to 12 at six sites over a three-year period.  Its goal was to more fully examine characteristics associated with better wellbeing of OAC as measured by cognition as well as emotional and physical health.  The POFO team successfully interviewed children and their caregivers through 2009-10 with a retention rate of >87%, and the study received international attention as the first multi-country observational study to follow a large cohort of post-toddler OAC. To date, six publications have resulted from POFO data; these describe the caregiving structures and characteristics that predict positive and negative outcomes for the children.

In 2010 the POFO study was awarded a five-year continuation grant (POFO II) to follow the same cohort through adolescence and young adulthood, up to ages 14 to 20. In addition to continuing to study predictors of physical, emotional, and cognitive wellbeing, POFO II will also examine important relationship outcomes and achievement outcomes among these OAC including risk behaviors and health promotion behaviors, educational achievement, job engagement, and family formation. The POFO II study period will conclude in 2015.

Positive Outcomes for Orphans (POFO) Sampling. We employed two-stage random sampling survey methodology in 6 geographically defined regions of 5 less wealthy nations to identify a sample of 1,357 institution-living and 1,480 community-living OAC ages 6-12 who were statistically representative of the population of institution- and community-living OAC in those regions. Baseline data collection was collected from community-based and institution-based OAC and their caregivers over 6 months at each site with 4 sites beginning in 2006 and 2 sites beginning as late as February 2008. Four primary baseline instruments collected information from: 1) single or double orphaned children reported to be aged 6 to 12 residing in communities or who were abandoned by both parents; 2) children residing in institutions; 3) the children’s primary caregivers; and 4) a person who could respond to administrative questions about the institution. Age inclusion criteria were based on survey instrument validity and pilot testing. Street children were excluded. Informed consent was obtained from each participating caregiver and from the heads of participating institutions. Assent was given by all participating children. Ethical approval was provided by the Duke University Institutional Review Board (IRB) and by local and national IRBs in all participating countries.

Country Selection. From a group of 13 countries in which the research team had existing relationships with grassroots community organizations with an interest in the proposed research, five countries were selected that were culturally, historically, ethnically, religiously, politically, and geographically diverse from each other. Political boundaries were used to define six study areas.

Institution Selection. For each of the six study areas, comprehensive lists of all institutions were created. To ensure broad representation, institutions were defined as structures with at least five orphaned children from at least two different families not biologically related to the caregiver(s). Institutions specifically for street children, special needs children, and international adoption were excluded. In total, 83 institutions participated in the study: 9 in Battambang, Cambodia (1 refusal), 13 in Addis Ababa, Ethiopia (2 refusals), 13 in Kilimanjaro Region, Tanzania (1 refusal), 14 in Hyderabad, India (5 refusals), 15 in Dimapur and Kohima Districts of Nagaland, India (2 refusals), and 21 in Bungoma, Kenya (no refusals). Reasons for refusals ranged from fear of psychological damage to the children to wanting monetary compensation for project participation (Box 1).

Selection of Institution-based Children. Each institution provided a list of all residential children under their care aged 6 to 12. At each of the six study sites, clusters were defined as villages, streets, or similar geographic units that were randomly selected from the respective next larger politically or administratively defined area (e.g., wards, kebeles, or other areas comparable to counties or zip codes in the United States). These areas in turn were randomly selected from all such areas within the boundaries of each study site. The number of clusters per study site ranged from 47 to 58 for a total of 311 clusters. Of the 5,243 children cared for by the institutions, 2,396 were reported to be age-eligible, and 1,360 were selected for enrollment. The number of participating children per institution ranged from 1 to 51.

Selection of Community-based Children. In each study area, the community sampling strategy involved the selection of 50 sampling areas (“clusters”) and 5 children per cluster. Geographic or administrative boundaries were used to define sampling areas: the specific definition varied across sites. Community-based study children were eligible if orphaned, as defined above, not living in an institution; or abandoned and living without either of their two parents. In each sampling area up to five eligible children were selected, either randomly from available lists, or through a house-to-house census conducted until 5 households with age-eligible children were identified. In households with multiple age-eligible children, one child was selected as the child whose first name started with the earliest letter in the alphabet. In total, 1,480 community-based children were enrolled in the study.

Caregiver Selection. The children’s (self-identified) primary caregivers were asked to respond to surveys about themselves and the children. In total, 193 institutional caregivers, ranging from 16 institutional caregivers in Nagaland to 52 in Cambodia, and 1,480 community-based caregivers participated in the assessments.

Data Collection and Follow-up.

During the initial study period (2006 through 2009-10), data on children’s health, physical growth and wellbeing, as well as characteristics of their caregivers and living situation were collected every 6 months for 3 years (Rounds 1-7). During the POFO II study period (2011-2015), interviews are conducted once a year (Rounds 8-11). Additionally, at four of the six study sites (all sites except Hyderabad and Nagaland), supplemental interviews will be conducted at 6 months post-Round 9 and post-Round 10 surveys to assess the structure and characteristics of children’s social and sexual partner networks. The POFO study is currently completing Round 9 interviews.

Data analysis is ongoing.