The Positive Outcomes for Orphans (POFO) study is a longitudinal cross-cultural research study designed to identify characteristics of care associated with better child outcomes. For the purpose of this work, an orphan or abandoned child (OAC) is defined as a child living without one or more of his/her biological parent. The POFO study is following approximately 2,750 children who were between 6 to 12 years at study outset and their caregivers in 83 institutional care settings and 309 community clusters in six study sites across five less wealthy countries: Cambodia, India (two sites), Kenya, Tanzania, and Ethiopia. Additional study details are located elsewhere .
Six geographically defined regions in five counties were chosen to represent cultural, historical, ethnic, religious, political, and geographic diversity. HIV prevalence differed across the countries as well. The 2007 estimated adult (15-49 years of age) HIV prevalence rate for each of the five study countries are as follows: Cambodia (0.8), India (0.3) with Nagaland estimated at more than twice that rate, Tanzania (6.2), Ethiopia (2.1) and Kenya (7.1-8.5) . Two-stage random sampling survey methodology was used to identify a sample of institution- and community-living OAC ages 6 to12 who were statistically representative of the population of institution- and community-living OAC in those regions.
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 resident OAC from at least two different families not biologically related to the caregiver(s). The institutional sampling frame was generated through inquiries to local government officials, schools, and organizations working with orphans. Institutions specifically for street children, special needs children, and international adoption were excluded. In total, 83 institutions participated in the study with only three being located in a caregivers home and all having more than five OAC: nine in Battambang, Cambodia (one refused), 13 in Addis Ababa, Ethiopia (two refused), 13 in Kilimanjaro Region, Tanzania (one refused), 14 in Hyderabad, India (five refused), 15 in Dimapur and Kohima Districts of Nagaland, India (two refused), and 21 in Bungoma, Kenya (none refused). Reasons for refusal ranged from fear of psychological damage to the children to wanting monetary compensation for project participation.
Selection of Institution-based Children
Institutions provided a list of residential children aged 6 to 12. Using a list of random numbers, up to 20 children per institution were randomly selected. When the target enrollment of 250 children could not be met at a particular site, for instance, in cases when there were not enough institutions from which only 20 children could be selected, then all children in the age range became eligible to participate. 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.
Community Sampling Area Selection
The primary community sampling aim was to select an unbiased sample of community-based care settings. In each of the six study areas, 50 sampling areas ("clusters") were selected. Geographic or administrative boundaries were used to define sampling areas, therefore specific definitions varied across sites.
Selection of Community-based Children
A community-based OAC was an orphan or an abandoned child (living without either of his/her two parents) not living in an institution. 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 five households with age-eligible children were identified. When the pre-identified sampling areas provided an insufficient number of community-based children, additional sampling areas were substituted; this occurred in 13 villages in Cambodia, 12 in Nagaland, and one in each of the remaining sites. 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, 1,463 community-based OAC were enrolled in the study.
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 protocol
Baseline data collection was conducted between May 2006 and February 2008 among community-based and institution-based OAC and their caregivers. Four main baseline instruments collected information from: 1) children residing in communities who had a parent who had died or was missing; 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. Informed consent was obtained from each participating caregiver and from the heads of participating institutions. Assent was given by all participating children. Interviews were conducted with children and caregivers using their native language in the child's residence and children were interviewed. Ethical approval was provided by the Duke University Institutional Review Board (IRB) and by local and national IRBs in all participating countries.
HIV-related stigma and acceptance
Caregivers were asked two questions: "If a relative of yours were sick with HIV, would you be willing to care for him or her"; and "Would you allow your child to play with an HIV-infected child". Caregivers could respond "yes," "no,", or "I don't know."
Caregivers reported age, gender, marital status, and educational attainment, whether they earned any income (for institution-based caregivers: whether they earned any income outside the institution), and, for institution-based caregivers, the number of years they had been a caregiver. Caregivers also rated their own health on a five-point scale (very good, good, fair, poor, or very poor).
Characteristics of the community-based and institution-based caregivers were described using means and standard deviations for continuous variables or counts and percentages for categorical variables. We fit logistic regression models, both for the full sample and separately for community-based and institution-based caregivers, to explore predictors of acceptance of HIV. The two stigma/acceptance variables were each coded so that the index category (coded as "1") corresponded to a response of "yes" (greater acceptance) while the reference category (coded as "0") corresponded to a response of either "no" or "I don't know." Thus an odds ratio greater than 1 in these models indicates a variable associated with greater acceptance. Logistic models included site fixed effects to account for the six recruitment sites. Analyses were conducted using Stata v.10.1.