Comparison of the Quality of Life of Vulnerable Children Resident in Household and Those Resident in Institution in Jos Nigeria

Background: There are over 143 million orphans globally, however, sub-Saharan Africa/Asian regions account for over 80% of the global burden (143 million orphans), Nigeria inclusive with over 10 million orphans. This has caused a crisis of shelter, as more children drift towards institutional care rather than staying in communities that are laden with a high prevalence of poverty (70% in Nigeria). This development is not the best practice in the care of Orphans and vulnerable children (OVC) based on national policy of OVC care which recommends Household rather than institutional care. Since studies have shown that Institutional care has a negative impact on a child, the place of placement is thus crucial to the outcome of vulnerable children (VC) which can easily be assessed by measuring the Quality of life (QOL). The aim of this study is to compare the QOL of VC living in Household against those living in Institutions. Methods: A cross-sectional comparative study involving 202 VC (aged 6-18 years) was Original Research Article Ishaya et al.; BJMMR, 16(8): 1-10, 2016; Article no.BJMMR.24092 2 conducted. VC were sampled using the multistage sampling technique across two orphanages and three communities located in suburban areas in Jos East, Jos North and Jos South Local Government Area. Outcome Measure: Quality of Life was determined using the WHOQOL BY (brief for youth) tool after validity and reliability test was done. The total score was transformed into a score of 1-100, with higher score implying higher QOL. Data generated were processed and analyzed using the EPI info version 3.5.1 statistical software. A score < -1 standard deviation (SD) from mean was considered poor, ±1 SD to -1 SD was considered fair and > ±1 SD was considered good. The student t-test was used for comparison of means while chi-square test or fisher exact test was used for comparison of categorical variables. In all statistical tests a p values ≤ 0.05 was considered significant. Results: The QOL score for the study population ranged between 47.2 to 95.2, the mean QOL was 75.2±8.1. The median and mode were both equal (QOL score of 75.2). Comparatively, IVC had higher mean QOL score of 76.9±7.0 compared to HVC 73.3±8.9 (p=0.002). IVC had higher scores compared to HVC in the following domain: psychological (p=0.05), social (p=0.004) and environmental (p=0.002). Conclusion: The QOL of VC in Institution is better than children in suburban Households in Jos Nigeria. IVC are better psychosocially and environmentally. However, a Qualitative study is needed for more depth.


INTRODUCTION
About 10% of Nigerian children are orphans (children who have lost father, mother or both) and much more made vulnerable due to unmet needs [1][2][3]. The rise in the number of Orphan and vulnerable children even though a global phenomenon has it highest impact in developing nations of sub-Saharan Africa and Asia where 80% of the global 143 million orphans resides [4]. This upsurge has lead to a shelter crisis, thereby pushing Vulnerable Children (VC) away from homes to seek shelter in orphanages or on the street. Aside shelter, VC lacks Parental supervision and protection and are more likely to encounter challenges accessing basic needs of education, health, food and clothing. All of these disadvantages may influence their Quality of life negatively [1,5,6]. The place of residence may influence the outcome of VC visa viz their various challenges in the context of their immediate and extended environment [5,7]. These interactions may worsen or improve the vulnerability of these children, ultimately determine their Quality of life (QOL) [8][9][10].
The placement of a VC in Institution or household determines both short and long -term outcomes, due to this relevance the Nigeria National policy on the care of orphans and vulnerable children (OVC) recommends households placement and not institutional placement for long -term care [5,7]. This recommendation is partly based on findings of worse outcomes of intelligence, cognition, development, attachment and even growth among Institutionalized children compared to non-institutionalized children, both residing in Europe [11][12][13][14][15]. Even though these studies are novel, they were however undertaken in developed countries which have different demographic and socio -cultural characteristic compared to Nigeria.
Studies from developing poor countries seem to show no difference or favor institutionalized care. A study in Low resources countries of Kenya, Tanzania, Ethiopia, Cambodia Hyderabad and Nagaland by Kathryn W et al. [16] found out that Health, emotional and cognitive functioning, and physical growth were no worse for institutionliving than community-living. In Eritrea, the observations were similar [17].
Few studies used a QOL tool as an outcome measure; QOL assessment is a personal, standardized measure of life satisfaction and well being across multiple domains that reflect the concept of health [18,19]: A state of complete physical, mental, and social well-being and not just the mere absence of disease or infirmity [20,21]. In Pediatrics/Child Health, QOL assessment assesses vulnerability, satisfaction to interventions and health need [18,19]. Stefan Erich used the WHO BY tool to assess the QOL of child-headed household in Bulawayo in South Africa [22].
There are however, no studies that compared the outcome of a VC in Institutional care against Household care in Nigeria, there are also no study on QOL of VC, neither are there studies that uses QOL as an outcome measure among household VC or institutional VC.
The aim of this study is to assess and compare the QOL of institutional and household vulnerable children in Jos, North -central Nigeria.

Study Sites
The study was carried out in 2 orphanages and 3 suburban communities in Jos, Plateau State Nigeria [23].

Study Subjects
The study subjects were vulnerable children living in the study area during the survey, who were resident in either a household or an orphanage.

Inclusion Criteria
A child who is less than 18 years but greater than 5 years and vulnerable. A vulnerable child was defined as a child who has lost either one or both parents, Lives in a household where at least one adult was seriously ill for at least 3 months in the earlier 12 months or children whose parent are alive but resides in orphanages.

Study Design
Cross-sectional comparative study. To take care of attrition, 20% attrition was added thereby making the minimum sample size of 102 VC from each subgroup.

Sampling Technique
A multistage sampling technique was used. From the list of 3 orphanages gotten from Child welfare department only two orphanages were included into the study because all inmates in third orphanage were below the age of 5 years. From the two orphanages sampled 99 VC and 3 VC were randomly sampled from the two orphanages based on proportion of children resident in the institution. Three Non-Governmental Organization caring for VC contacted households with VC in three sub-urban communities namely Tanchol, Sabon Fobur and Mado Village in Jos Eeast and Jos north LGA. In each of these selected community 34 VC were randomly sampled.

Preparation for Data Collection
Research assistants were trained to use the research tools.

Translation of the Instrument
The WHOQOL BY was translated into Hausa and back into English by a linguist.

Ethical Issues
Ethical clearance was obtained from the Jos University Teaching Hospital (JUTH) ethical review board. Verbal Permission was obtained from the community leaders and heads of orphanages. Written informed consent was obtained from the parents/caregivers of each child (in form of a signature or a thumbprint) participating in this study.

Data Collection
Data collection was done using an intervieweradministered questionnaire. The information generated included demographic and social variables. The QOL tool was interviewer administered to all children by the researcher and one assistance in order to obtain a consistent result.  [20,22].
Each of the items had 5 responses namely very dissatisfied, dissatisfied, medium, and satisfied and very satisfied which was scored as 1-5 respectively. For the presentation of data on each item the 5 point scale was collapsed into 3 scales namely positive (very satisfied and satisfied), medium or negative (dissatisfied and very dissatisfied) [19,20].
The total score was transformed into a score of 1-100 with higher score implying higher QOL.
A normal distribution curve was then plotted for each study population. A score of < -1 SD from the mean was considered poor, ±1 SD to -1 SD was considered fair and > ±1 SD from the mean was considered good [25].

Data Analysis
Data generated were processed and analyzed using the EPI info version 3.5.1 statistical software. The mean and standard deviation of continuous variables such as age, QOL score and domain score were computed. Frequency distribution tables and contingency tables were drawn. The student t-test was used for comparison of means while chi-square test was used for comparison of categorical variables in the contingency tables. Where expected cell values were less than five, the Fischer exact test was used. In all statistical tests a p-values ≤ 0.05 was regarded as significant.

RESULTS
Two hundred and four OVC were recruited for the study. Two of the households OVC were withdrawn from the study because of incomplete data. Therefore only 202 OVC were analyzed.

Characteristic
The mean age of the studied population was 12.7±2.6 years with an age range of 6-17 years. The mean age in years of IVC was 12.8±2.5 while that of HVC was 12.6±2.5. This difference was also not statistically significant (p=0.4611). Out of the 202 VC analyzed, 124 (61.4%) were males while 78(38.6%) were females, giving a male/ female ratio of 1: 0.6. Of the 124 males VC studied, 65 (52.4%) male VC resided in the institution while 59 (47.6%) reside in households. Out of the 78 females analyzed 41 (52.6%) resided in the household while 37 (47.4%) reside in the orphanage.

QOL of Subjects
The QOL score ranged from 47.2 to 95.2, with a mean score of 75.2±8.1. The median and mode were both equal (QOL score of 75.2) thus assuming a normal distribution. Comparatively, IVC had higher mean QOL score of 76.9±7.0, compared to HVC (73.3±8.9). This difference was statistically significant. (p=0.002). See Table  1for

DISCUSSION
In the present study the proportion of VC with good QOL was twice the number of VC with poor QOL. This is somehow surprising considering the challenges faced by these children [5,6]. There are however no study to compare with but the possible reason for this relative good QOL among VC in this study might be related to the ownership of these Institution which are largely private own in this case by FBO (Faith Base Organization). It is also possible that the cultural support given to the needy is still viable in these communities; it may also be due to the development of resilience and coping mechanism by these VC as observed by Stefan E in South Africa [22].
The QOL of IVC was better than that of HVC, this finding is comparable with finding of a better subjective score among children age 6-12 years, residing in low resource countries, as reported by Katryn W et al. but contrast to a study in Poland where the QOL was higher for household vulnerable children [14,16]. In low resource countries where a lot of families live below the poverty line, some of these institutions, especially the private owned, may have more resources than some households. This has implications on child food security, school enrollment, availability of clothing's, physical and emotional health status and eventually the QOL.
The difference in the past life events will influence a child's long term outcomes which may reflect in cross-sectional studies. For example, children in institutions may have experienced the orphaning at a later age, when they are less vulnerable, relative to the children in the community. However, this variable was not analyzed because the majority of IVC and their current caregiver were not sure of the age at which these children were orphaned.