Recommendations for* child welfare care reform in the global south: Perspectives of 542 adults who were separated from parental care during childhood in 12 nations

Abstract

A robust literature has outlined the risks to children separated from parental care. Recently, there has been an effort to reform services to this population. However, the research driving reform has often neglected the voices of adults with care experience, especially those from the Global South. The current research explored recommendations for care reform from 542 adults who had experienced alternative care during childhood in 12 nations in the Global South. Data revealed three themes to improve care: (1) child focus and participation, (2) the need for family placements, and (3) the importance of support services. Implications are discussed.

INTRODUCTION

Globally, millions of children and youth are separated from biological parental care during childhood for a variety of reasons, including poverty, parental death and maltreatment (Desmond et al., 2020; Wilke et al., 2022). During these separations, children often reside in alternative care settings, which may include residential care centres, kinship care or foster care (Martin & Zulaika, 2016). Long-term outcomes for children and youth separated from parental care are often poor (McGuire et al., 2021), particularly for children in residential care (van IJzendoorn et al., 2020). As such, researchers (Berens & Nelson, 2015; Dozier et al., 2014) and policy-makers (United Nations General Assembly, 2019) have called for care reform to improve services for this highly vulnerable population.

However, little of this work has considered the voices of adults who resided in alternative care settings during childhood in a systematic way (Dixon et al., 2019; Hartworth et al., 2021). Adults with alternative care experience can provide important and unique insight into the needs of children currently in care and how services could be improved (Dixon et al., 2019; Hartworth et al., 2021). Furthermore, it offers individuals with care experience the opportunity to influence research, practice and policy based on their knowledge and experience (Harder et al., 2020). The research that does exist has primarily been conducted in nations in the Global North (Roche & Flynn, 2020). Due to disparity in resources and differences in care systems, the results of these studies may not generalise to the Global South (van Breda et al., 2020). The current study surveyed adults who had experienced alternative care during childhood in nations in the Global South about their thoughts, beliefs and recommendations regarding care reform and services in alternative care settings.

Improving outcomes for children and youth

Individuals who needed alternative care during childhood are widely recognised as a vulnerable population (Berens & Nelson, 2015; McGuire et al., 2021). Research has consistently found that adults with care experience are at significantly greater risk for negative outcomes (van IJzendoorn et al., 2020). Berlin et al. (2011) found that adults with care experiences were more likely to attempt suicide, abuse substances and engage in criminal behaviour. Other work has documented lower rates of post-secondary education, higher rates of unemployment or underemployment and higher levels of poverty (Dickens, 2018; Diraditsile & Nyadza, 2018). Furthermore, general early adversity has been linked to a higher likelihood of chronic illness and lower life expectancy (Felitti & Anda, 2010), challenges with executive functioning (Lund et al., 2020), atypical behavioural development and mental health concerns (Hanson et al., 2017). These outcomes have led to serious concerns for the well-being of children and youth separated from parental care, both in childhood and adulthood.

In the past few decades, policy-makers and researchers have given attention to the need to reform alternative care for children for the purpose of improving outcomes (Goldman et al., 2020; Strahl et al., 2021; United Nations General Assembly, 2019; van Breda et al., 2020; van IJzendoorn et al., 2020). Key themes have included the value of family preservation, deinstitutionalisation, child focus and participation and supporting transitions to adulthood (Goldman et al., 2020; Murphy et al., 2017; Wilke & Howard, 2021).

The voice of adults with care experience

Although care reform proposed by researchers and policy-makers have played an important role in improving child outcomes, they have often lacked meaningful input from those they hope to serve. Adults with care experience can offer insights about what was helpful or unhelpful during their time in care and can make experience-informed recommendations for supporting children in care. Although they may continue to experience some vulnerabilities after leaving care (Dickens, 2018; Diraditsile & Nyadza, 2018), many adults with care experience are significantly less vulnerable than children in care and possess greater agency, support and capacity to participate (McGee et al., 2020).

This population can provide in-depth care knowledge and experience to benefit current and future research, policy and practice (Dickens, 2018). Furthermore, adults with care experience are calling for their own participation in research and policy related to children separated from parental care (Hartworth et al., 2021). A few studies have investigated care reform recommendations of adults with care experience, but most of these have had fairly narrow scopes, small sample sizes or focused primarily on adults with care experience from the Global North (Dixon et al., 2019; Hartworth et al., 2021; van Breda et al., 2020). As such, the aim of the current paper is to examine the valuable thoughts, beliefs and recommendations regarding care reform of adults who had experienced alternative care during childhood in nations in the Global South.

The present study

The objective of the present study was to identify recommendations for care reform from adults with care experience from the Global South. Rather than focus on trends between types of care, country or reasons for placement, the current study was interested in overarching themes that emerged. To better understand the perspectives of this population, the current study surveyed a multi-national sample of adults who had experienced alternative care settings as children in nations in the Global South, such as residential care, kinship care or foster care. Specifically, respondents reported their beliefs about what children in care need most for healthy development and what recommendations they would make to better support the well-being of children and youth currently in alternative care. This knowledge could allow service providers to learn from the experience of adults who were separated from parental care as children, informing better practices and policies for children currently separated from parental care in nations in the Global South.

MATERIALS AND METHODS

Sampling

The population for this study was adults who were separated from parental care as children in the Global South. Participants were recruited using a combination of volunteer, convenience, snowball and chain referral sampling. Recruitment notices were posted on the website of a coalition connecting more than 200 non-government organisations serving vulnerable families, distributed by email through relevant professional networks that serve adults with care experience, and emailed to potential participants using organisational and professional networks' distribution lists. The recruitment information was further disseminated via chain referral sampling.

Participants were 542 adults with care experience. All were separated from biological parental care for at least 6 months during childhood. Participants reported residing in 12 Global South nations during childhood (see Table 1; i.e. the nation in which they were separated from their biological parents). The most commonly reported nations of residence during childhood were India (n = 146), Kenya (n = 113) and Zimbabwe (n = 58). Frequencies and percentages for nations of residence during childhood can be found in Table 1. Participants ranged in age from 18 to 89 (M = 26.48; SD = 7.83). The majority reported being single (65.7%). See Table 2 for additional demographic data.

TABLE 1. Frequency and percentage for nation of residence during childhood for nations

TABLE 2. Participant demographic

Data were collected as part of a larger initiative focused on healthy development in adults with care experience worldwide. All participants completed an online survey consisting of demographic items, 15 open-ended questions regarding their time in care, and several validated measures that were translated into Spanish, Hindi and Thai. The current study reports on a subset of these items. The current study only included participants whose nation of residence during childhood (i.e. the country where the separation from biological parents occurred) was in the Global South and had 15 or more respondents to the survey. Twelve nations meet this criterion (see Table 1).

Measures

General demographics

Participants answered a series of questions regarding their current age, nation of residence, gender, ethnicity, education, marital status, whether they have children and employment status.

Care experience demographics

Participants were asked questions regarding their experiences when separated from their biological parents. Items included nation of residence during childhood (i.e. where the separation occurred), age at initial separation, reason(s) for the separation, type(s) of placements and total number of placements. It is important to note that many individuals with care experience reported there being multiple reasons for their initial separation from their biological parents and that they experienced multiple types of placements during their separation. As such, these items were check-all-that-apply closed lists, where participants could include additional text for ‘other’ circumstances.

Care experience survey

All participants completed a survey containing 15-open ended questions regarding their experiences surrounding their separation from parental care. Items analysed for the current study included: (1) What do you think is the most important thing for supporting children separated from their biological parents?, (2) If you could change one thing about care for children separated from their biological parents, what would it be?, (3) What do you want people to learn from your experience? and (4) Is there anything else you would like us to know?

Translations

Survey items were translated from English to Spanish, Hindi and Thai. For qualitative items, participants responded in one of these languages. Guidelines proposed in the literature on cross-cultural methodology (Brislin, 1980) were followed as closely as possible. Specifically, independent (blind) back translations and educated translations were conducted. For each language, two bilingual content experts translated all survey items and participant responses. At least one translator for each language was a native speaker. Discrepancies were minimal, and translators came to consensus through discussion for any divergences.

Data analysis

This study used a qualitative research design (Creswell, 2013). Some quantitative data, mainly frequencies and percentages, were used to support qualitative data and provide insight into the participant's reflection. The four open-ended items were examined using qualitative thematic data analysis. Two researchers manually coded all open-ended questions and analysed every question independently. Themes within the questions were clustered, and the coders developed a directory of operational definitions and keywords corresponding to the major themes. A description of relationships between the themes and individual items was written and considered before drafting the final qualitative results. Quotes, including both full sentences and sentence fragments, were used to support the results.

Ethics

Ethical approval was obtained from the author's Institutional Review Board. All measures were completed using an online survey platform, and items were presented in random order. Participants gave informed consent by checking a box. Informed consent detailed the purpose of the study, procedures, risks, benefits, privacy and confidentiality. All participants provided informed consent before completing the survey and were free to end the survey at any time. Completion rate was 74.0%.

RESULTS

Descriptive statistics regarding care experiences

Age at initial separation from biological parents ranged from 0 to 15 (M = 6.66; SD = 4.44), where 0 indicates that the participants were separated during the first 12 months of life. Only 6.6% (n = 36) reported being separated during the first 12 months of life. Participants reported a range of reasons for the separation from biological parents, with the most common being parental death (41.7%), poverty (23.8%) and abandonment/relinquishment (19.9%). Total number of reasons for separation from biological parents ranged from 1 to 9 (M = 1.64; SD = 1.12). More than half of participants reported having more than one placement (55.0%; n = 298) after being separated from their biological parents. Total number of placements ranged from 1 to 19 (M = 2.27; SD = 2.32). Participants also reported a variety of types of placements, with the most commonly reported being kinship placement (71.8%), residential/group care (67.9%) and foster care (20.3%). Participants experience between one and six types of placement (M = 1.51; SD = 0.77). These findings suggest that placements were relatively stable with high rates of kinship and residential care.

Qualitative thematic analysis

The responses to the four open-ended questions clustered into the following three themes: (1) Child Focus, (2) The Need for Family and (3) Support Services. Within each theme, subthemes are presented. Discussion of each subtheme includes (1) a description of the theme including the total number of references for the subtheme across all responses by all participants, (2) representative quotes that highlight the subtheme and (3) and a brief summary of the data and contextual details needed for interpretation.

Theme 1: Child focus

One consistent theme throughout the data was the need for more child focus in care for children and youth separated from their biological parents. Respondents frequently reported that they believed the needs and desires of the children in care were overlooked as they moved through the child welfare system. Study participants indicated that children and youth should be more involved in the decision-making process and that service providers should be better equipped to meet the individual needs of the children. Although subthemes varied based on context and care experience, those that occurred most frequently were (1) Trauma-informed Training for Service Providers, (2) Access to Information About Origin and (3) Child Participation in Care Decisions.

Trauma-informed training for service providers

The need for caregivers, support professionals and others surrounding children separated from parental care to have trauma-related training and competency was a recurring theme (n = 242). This subtheme related to trauma, trauma history, the effects of trauma and the need for a trauma-informed approach. The following quotes highlight the importance of adults in the child's life to be well-informed about trauma and its effects:

• “Better education and training for caregivers. This whole experience isn't for the caregivers, it's for the children. Their focus should be how to make things as best they can for the children, not how to make the best fit for the parents.” (Male/28/Mexico)
• “All individuals involved in that child's care should be well trained in attachment and trauma and have the ability to implement strategies to effectively support that child.” (Male/44/India)
• “If I could change one thing it would be that ALL caregivers were more trauma-informed. I sincerely believe that if all entered this process with a better understanding of trauma, there would be fewer moves and fewer placement disruptions.” (Female/47/Zimbabwe)

Data suggested individuals with care experience believe adults supporting children separated from parental care should have trauma training and competency.

Access to information about origin

The need for children and youth to have access to information about their origins was also a substantial theme (n = 136). Participants emphasised access to information about origin as a fundamental right that should be prioritised by the child welfare system. This included both access to information about the child's family and the importance of maintaining a child's connection to his or her community and culture, even from a young age. This theme also included a call for easy access to legal records. The following quotes highlight the importance of access to information about origin:

• “Openness and full disclosure with the child about biological family of origin history. The empirical evidence suggests that openness can aid in grief resolution for the child (and birth parent).” (Female/30/Kenya)
• “All children need unrestricted access to their records. It's absolutely ridiculous that we are left in the dark and that genetic testing is only available to those that can afford it.” (Male/26/Ethiopia)
• “That your biological heritage matters. Too many people are dismissive of it. Even my own biological relatives tell me I got the better deal than them, simply because I was marginally better off financially … Paternal bio brothers have no idea how it feels to not know where you came from and don't understand why I searched for them.” (Male/30/DR Congo)

Data suggested individuals with care experience perceive a distinct need for children separated from parental care to have access to information about their origins, including community, culture, and legal records.

Child participation in care decisions

Participants frequently raised concerns that placement, as well as other decisions, were made without consulting the child or children involved (n = 183). Indeed, many participants reported that while in care they were often not aware of why decisions were made, what to expect as a result of these decisions, or even that upcoming changes in care were imminent. Overwhelmingly, related quotes indicated the necessity of ensuring children and youth were made aware of decisions and changes and had a voice in the process. The following quotes highlight the perceived need for transparency and child participation in care decisions:

• “I feel it is critically important for the children who are removed to stay informed and have a true understanding of what is happening. I remember having no idea what was happening in my life. That feeling led to significant fear.” (Female/28/Peru)
• “Do not force them to keep contact with anyone from their biological family. If they want to do so, they will, but don't make it obligatory.” (Female/23/Rwanda)
• “Listen to the child if they say the situation is bad it's probably bad, I was stuck in my second placement for 3 years being abused and I cried out multiple times and was told I was lying.” (Female/19/South Africa)
• “Have the kids participate in their case more. I didn't get adopted till I was 8 years old and during the court hearing the judge looked at me and asked me if I wanted to be adopted and I paused (noticeably) before answering yes. Years later I'm walking with my father outside because it was nice out and he brought that up and asked me why I paused. I said it was the first time anyone ever asked me what I wanted.” (Male/27/Ethiopia)

These findings suggested that adults with care experience believed that children separated from parental care need to be informed of and involved in care decisions.

Theme 2: The need for family

Another emergent theme was the need for all children to be in a family. This included both the importance of individual children being placed with a permanent family as well as a more systemic call for moving from an institutional or residential model of care to a family model of care for separated children. Subthemes varied, but those that occurred most frequently were (1) System Reform, (2) The Importance of Family Preservation and (3) Maintaining Contact with Biological Family Members.

System reform

Individuals with care experience, particularly those who were placed in residential care settings during their separation, frequently highlighted the need for a child to have his or her own stable, permanent family (n = 180). This included biological, extended or alternative family care. It was often noted in contrast to residential care or rotating caregivers. There was a consistent call for child welfare systems to be reformed to provide family placements for all children and youth. The following quotes highlight the perceived need for family:

• “Doing away with orphanages/children's home as an option to help a vulnerable child. Create a family-based care model/system that supports the community and families as well as strengthening the families by offering both financial sustainability and psychosocial support for the well-being of the child and the community at large thus eventually overcoming the need to condemn more children to institutionalisation.” (Female/22/Thailand)
• “In most cases, the #1 reason many children wind up in orphanages is because of poverty. Separating children from their families by bringing them into orphanages doesn't really solve poverty but it deepens the trauma in children. We do not lack families. What we do need is bold leadership to equip and empower those families to bring home-made solutions to the underlying problems leading to poverty.” (Female/42/China)
• “Family love and care is the most important thing ever. if there is real love for one child they will grow healthy and can face any life's challenges.” (Female/26/Mexico)

These findings suggested that adults with care experience believed that living in a family was one of the most important factors for children and youth separated from parental care.

The importance of family preservation

The need to prevent children from separation from parental care was also a recurring theme (n = 228). Participants' responses centred around the need for more robust family strengthening support. Data revealed a clear call to prioritise keeping children with their biological parents, if possible. When not possible, participants frequently noted the value of kinship or extended family placements to be the primary source of care. The following quotes highlight the importance of family preservation:

• “Society needs to prevent the conditions that lead to separation and relinquishment and fight to keep children within at least an extended kin situation.” (Female/27/DR Congo)
• “Recognize that children being in care is a temporary arrangement and that with the correct support, children should be able to reunite with their families.” (Male/42/Peru)
• “Preventing children from ever being separated from their parents, siblings, and other family in the first place by investing in supportive social and community programs that serve families' needs.” (Female/31/DR Congo)

Data suggested individuals with care experience perceive a distinct need for family preservation and, when necessary, kinship placement.

Maintaining contact with biological family members

The need to maintain contact with biological family members was also frequently (n = 103) reported. Specifically, participants recommended continued contact with immediate and extended biological family members when prevention of separation and kinship placements were not possible. Some acknowledged that contact with certain individuals might be unsafe, but that maintaining contact with other family members should be made a priority. Many participants reported grief at not being able to regularly communicate with parents, siblings, grandparents and extended family members. At the same time, some participants stated contact should be available, but at the discretion of the child. The following quotes highlight the importance of having the opportunity to maintain contact with biological family members:

• “If the child wants to see their first-family then let them, if it's safe to do so. If safety issues exist then allow phone calls and letter writing to occur until it is safe for physical visits.” (Male/22/India)
• “Ensuring they have on-going and regular contact with their parents, siblings, family and extended family.” (Male/42/Kenya)

Data suggested individuals with care experience would prioritise the option for regular communication with biological family members for children separated from parental care.

Theme 3: Access to support

The final overarching theme highlighted the need for access to support for children and youth separated from parental care. This theme relates to supporting the child's well-being by acknowledging complex needs and providing the child access to support services while in care and beyond. Subthemes that occurred most frequently were (1) Availability of Support Services, (2) The Value of Peer Support and (3) Support During the Transition to Adulthood.

Availability of support services

The most prominent subtheme reported by participants was the need for children and youth separated from parental care to have access to support services (n = 373). Participants clearly believed this population needed additional support beyond those which were typically available for children. A variety of specific services were mentioned, including those related to health, education, finances and psychosocial support. However, responses indicated that access to services in general was a primary concern. The following quotes highlight the importance of having access to support services:

• “For me its financially, spiritually, and emotionally support. I believe every child needs proper education and care. I didn't finish my college since I don't have enough source of funds and I'm too shy always asking for help specially with relatives.” (Male/27/Uganda)
• “Because I came from a biological family with a history of substance abuse there should have been more targeted services toward me transitioning as I am most at risk to repeat the cycle. Luckily I broke that cycle myself. However, if a mother has three children and those three children don't break the cycle then those three children each have three children who don't break the cycle because proactive services are not available, then we are creating bigger problems.” (Female/48/Kenya)
• “Also have a huge need for emotional support and counselling. They need help processing their loss, fears and feelings.” (Female/19/India)
• “I think there needs to be more counselling sessions. I think counselling children is helpful.” (Female/28/Uganda)

Findings suggested individuals with care experience would prioritise access to support services for children separated from parental care.

The value of peer support

The need for peer support was a strong element in participant responses (n = 54). Data revealed that participants believed that having relationships with and support from peers who had similar care experiences were important for supporting long-term positive outcomes of children and youth separated from parental care. The following quotes highlight the value of peer support:

• “To have someone he can really talk with … someone in his age that will understand his pain and support him.” (Male/21/Zimbabwe)
• “I feel like if we were to make more community-related events where foster youth of all ages could get together and grow in those relationships where they feel more in common with others, maybe they can gain that sense of family through their situations.” (Female/34/Peru)
• “That they would be introduced to other children who are joyful, stable and real with stories to share … To make it known to them that they are not alone and there is hope and joy and life through the crazy of the journey of life.” (Female/29/Kenya)

Data suggested individuals with care experience perceive a need for children separated from their parents to have access to peer relationships and support.

Support during the transition to adulthood

Although many participants received substantial support during childhood, they did not have sufficient support during their transition to adulthood. A robust subtheme within the data was the need for more targeted and comprehensive long-term support services for youth making the transition to adulthood (n = 213). The following quotes typify the need for more support in the transition to adulthood:

• “Children ageing out should have the experience of living on their own in a separate shelter rather than being included. This is where they will learn to have a life of their own, cook their own food, make decisions that concern them and be more exposed to the community with someone guiding them. This will be easier for them to transition to adulthood.” (Male/18/India)
• “Make sure that they are aftercare support services for children who have left care. the policies that discriminate against children because of their age should be changed immediately.” (Female/24/Uganda)
• When they are discharged they are expected to fend for themselves and be grown ups, while the same children not in care are being supported by their relatives and parents.” (Male/24/Uganda)

Data suggested adults with care experience believed there was a need for more targeted, strategic and effective support services for youth transitioning to adulthood.

DISCUSSION

Recently, there has been momentum to reform services for children separated from parental care. However, the research driving this work has seldom directly investigated the recommendations of individuals who resided in these settings during childhood (Dixon et al., 2019; Hartworth et al., 2021). Furthermore, most of this work has focused on individuals from the Global North (Dixon et al., 2019; FICE International, 2016; Harder et al., 2020; Hartworth et al., 2021). Findings from the current study suggest adults who were previously in alternative care in nations in the Global South have powerful perspectives that could supplement current research and better inform the care reform process. Data revealed that participants believed that the voices of children and youth should be paramount in care decisions and that service providers should be better equipped to meet the individual needs of the children. Moreover, findings strongly suggest that adults who experienced alternative care during childhood in nations in the Global South supported deinstitutionalisation and believed that family-based placements were critical for long-term positive outcomes. Finally, data highlighted the value of and need for access to robust long-term support and services for children and youth separated from parental care. The current results are consistent with findings from the Global North (FICE International, 2016; Harder et al., 2020). However, they also highlight distinct challenges in the Global South, especially surrounding family preservation and deinstitutionalisation. These distinctions are also consistent with research suggesting that areas of the Global South have less well-developed social policy and aftercare services (Strahl et al., 2021). Findings from the current study were used to inform the below recommendations.

Recommendations

The research team provides the following recommendations based on current findings to help organisations better target resources to meet the needs of the children and youth separated from parental care. Recommendations based on results from the current research were developed after evaluating global guidance (i.e. United Nations General Assembly, 2019, etc.) and an intensive review of the academic literature. These sources were synthesised into a list of priorities that were then categorised into themes. Drafts of the recommendations were reviewed by content experts, including adults with care experience, service providers and academic researchers. The recommendations were then refined based on feedback. This led to six recommendations for service providers.

Prevent family separation

A major theme in the current study was preventing separation and family preservation. Millions of children around the world are separated from parental care (Desmond et al., 2020), and many more are at risk of separation (Hillis et al., 2016). One way to prevent the negative outcomes associated with alternative care is to prevent separation. In alignment with the recommendations of study participants, research suggests that separation can often be prevented with family strengthening support (Goldman et al., 2020). Furthermore, there is increasing evidence that families who were separated can be successfully reintegrated with appropriate support (Murphy et al., 2017). Research (Goldman et al., 2020; van IJzendoorn et al., 2020; Wilke & Howard, 2021) and policy (United Nations General Assembly, 2019) are increasingly calling for the prioritisation of family preservation.

Prioritise family care

Although remaining safely with biological family is the ideal, alternative care may be necessary for some children. However, participants in this study repeatedly emphasised the need for each child to have a permanent and stable family. This is in alignment with broader research, which has suggested better outcomes for children in alternative family care than for children in residential settings (van IJzendoorn et al., 2020). This work has led to a shift in global policy which prioritises family-based models of care and recommends the use of residential care only as a last resort for children separated from parental care (Goldman et al., 2020). Furthermore, previous work has outlined processes and outcomes of programs that have transitioned their models from residential to family care (Wilke & Howard, 2021; Wilke et al., 2021).

Build capacity in service providers

Increased access to professional and informal support was a clear recommendation from participants in this study, including greater training and capacity for service providers serving vulnerable children. These individuals included professionals such as psychologists, lawyers, social workers and teachers as well as direct care providers and program staff. There was a call for training in trauma-informed care, which aligns with the current research (Lotty et al., 2020). In person training would be ideal, but virtual options do exist, which may be especially helpful in difficult-to-reach or low-resource settings.

Increase transparency with youth in care

A prominent theme in the current data, and in the larger care reform literature, is the need for services to be focused on the child. Although there are numerous systemic factors that influence the well-being of children (Bronfenbrenner, 1979), individual factors play an important role as well. This means uniform approaches to care are unlikely to meet the needs of all children. The best interest of the child is a core principle of global guidance (United Nations General Assembly, 2019). Research has supported the positive impact of child participation in care decisions on care outcomes (Kennan et al., 2018). Rather than decisions being made solely by professionals, there is increasing recognition that children should be involved in care decisions at developmentally appropriate levels (Harder et al., 2020).

Create opportunities for connection

A clear priority of the participants in this study was connection and maintaining relationships. Related to this, a prominent theme was for connection with biological families. This aligns with research supporting continued contact (Harder et al., 2020; McWey & Cui, 2021; McWey et al., 2010; Sanchirico & Jablonka, 2000). One key point was that contact should be with the permission and desire of the child, not only of the parent or service provider. If contact with parents is not safe or wanted, pursuing other relationships, such as those with siblings, grandparents or extended family, can be a valuable alternative for helping the child to remain connected to his or her family and history. When family is not available, contact with fictive kin may fill an important role (Leon & Dickson, 2019). This may include teachers, neighbours, family friends, coaches or other community members who have played a supportive role in the child's life. Furthermore, participants noted the value of contact with peers who also have alternative care experiences. Children in alternative care should be supported in forming and maintaining close relationships with others during their time in care.

Increase access to support Services for Children in care

Understanding that separation from parental care is a serious adversity for children, there may be many needs that arise for children in care. Participants in this study noted this as a primary need for children in care, and one that is often not met. Care leavers need access to high-quality support services (Harder et al., 2020). Ensuring access to support services across domains will improve the likelihood of positive outcomes. These services should include individual and/or family case management, education, health services, psychosocial support, life skills training and recreational activities. Access to services should persist through the transition to adulthood (van Breda et al., 2020), ensuring the individual has adequate support to achieve a stable living environment and routine.

Provide navigation support for transitions

Participants revealed that even when support existed during childhood, the transition to adulthood was often unsupported. This phase can be especially difficult for children separated from parental care, and support specifically for youth transitioning to adulthood was noted as a primary need. Anxiety surrounding the transition to adulthood can be reduced by professionals, policy-makers and researchers prioritising navigation support before, during and after the transition to adulthood (van Breda et al., 2020). Navigation support includes, but is not limited to, mapping of resources (housing, livelihood, medical, education), life planning, social support mapping, service coordination and family finding/engagement.

Limitations and implications for future research

The current study had major limitations that should be considered when interpreting the findings. These may also serve as catalysts for future work. The current sample provided an adequate snapshot of the general thoughts, beliefs and recommendations of adults with care experience, but it is limited in several ways. Although having a multi-national sample of participants with a range of care experiences allowed the researchers to explore a greater breadth of responses, the heterogeneous nature of the sample made it difficult to generalise themes across all adults with care experience. As a result, the themes discussed in the current manuscript may not fully reflect the beliefs and recommendations of all adults with care experience but are rather general trends among the population. Participants ranged in age from 18 to 89. It is worth noting that care practices and policies may have changed substantially since some participants were separated from parental care. Future work should focus on recruiting more representative samples that are equally distributed across nations to better capture the experiences of all adults who were separated from parental care during childhood.

Another set of limitations focus around methodology. Convenience and snowball sampling were utilised in the current study. It also was a one-time, online survey. These methods were used because they were inexpensive, efficient, and simpler to execute, especially in a multi-national study of this scale. However, a major disadvantage of all these approaches is lack of clear generalisability due to heterogeneous sampling and the unequal distribution of numbers of participants across nations. Indeed, the current participants likely represent a subset of a broader population of all individuals that were separated from parental care during childhood. For example, in order to participate in the current study participants had to have access to the internet and be literate. As a result, the current sample is likely biased towards educated participants with a higher socioeconomic status and more positive long-term outcomes. Future work should consider employing more robust and representative sampling methods. Longitudinal research as well as focus groups or interviews should also be considered.

Although the researchers followed guidelines for cross-cultural research (Brislin, 1980), several limitations remain. First, the current survey was only translated into a few languages. Future work should increase the number of languages available. Second, although non-English responses were translated and back translated, they were coded in English. It is possible that the nuances of the responses were impacted as a result of translation. Despite the fact that the commonalities in responses across nations were profound, future research should obtain larger samples in each nation and focus on culture-specific themes.

CONCLUSION

Adults with care experience have a critical role to play as we continue to refine our approaches to care reform globally and in the Global South in particular. Their voices must serve a central role as we consider policies and practices for serving vulnerable children and families in these nations. Participants of this study who spent their childhood in alternative care in nations in the Global South outlined a clear need for improvement. Data revealed three themes for improvement in care: (1) child participation and customised care provision, (2) family placements for children and (3) improved access to support services. These themes align with previous research about which interventions will support better health and well-being outcomes for children in alternative care. By understanding the recommendations and perspectives of this population, service providers and policy-makers can make more informed decisions regarding priorities for services and practices to benefit children separated from parental care.

ACKNOWLEDGEMENTS

The authors thank the participants of this study, as well as partners including Udayan Care, the Kenya Society of Care Leavers, Rwanda Network of Care Leavers, Uganda Care Leavers, Zimbabwe Care Leavers Network, CAFO member organisations and all who gave input to this project. Laura Nzirimu was a tireless advocate in supporting the data collection process, and has our deepest gratitude. The authors also thank UBS Optimus Foundation for providing the funding that made this project possible.

ETHICS STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to their containing information that could compromise the privacy of research participants. All authors of the present study certify that they have no affiliations with or involvement in any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. As such, the authors do not have any conflict of interest. This study was approved by the Institutional Review Board at Samford University on 9/15/2020 (EXMT-A-20-F-2). All participants completed an informed consent.

Biographies

Nicole Wilke serves as Director of the Center on Applied Research for Vulnerable Children and Families at the Christian Alliance for Orphans. The focus of this work is to connect the best available evidence to frontline practice in the care of children and families at risk. Her research interest focuses on improving services for children outside of parental care.

Megan Roberts is a graduate of Samford University. She is currently pursuing her Master of Social Work at Auburn University. She is also a research assistant at the he Center on Applied Research for Vulnerable Children and Families at the Christian Alliance for Orphan.

Ian Forber Pratt, MSW works in the field of child protection and childcare system reform in the United States, India, Sri Lanka, and globally. He completed his master’s in social work from Washington University’s George Warren Brown School of Social Work and is currently the Director of Global Advocacy for CERI based in San Antonio Texas and the Executive Director of the Institute for Child Welfare Innovation based in St. Louis, Missouri, USA. Mr. Forber Pratt is passionate about bridging gaps between policy and practice in the fields of child welfare and protection at global, state and local levels.

Grace Njeri is a child protection advocate. She earned her bachelor’s degree in sociology from Moi University. Grace is heavily involved in care reform for children in alternative care and mentoring youth transitioning to adulthood.

Amanda Hiles Howard is an Assistant Professor of Psychology at Samford University. Her research interests focus on understanding the impact of adversity on development and improving quality of life for vulnerable children and families. She is also committed to translating research to practice via public policy, advocacy, and education.