Institutional child care has been a practice used globally for many years in circumstances where parents are unable to provide suitable care, or in instances of parental death where no remaining family members are willing or able to take custody of a child. Prior research indicates that residential facilities often have inadequate resources, high child-to-caregiver ratios, and frequent change in caregivers on staff (Dozier et al., 2012). These circumstances leave many children deprived of the sensitive, loving care often provided by parents, which is necessary to build healthy attachments and develop into competent, well-adjusted adults. The abundance of research highlighting the damaging effects of institutional care led to the United Nations publishing the Guidelines for the Alternative Care of Children which state that best practice is to place children in family care, and countries should take steps to eliminate institutionalized residential care facilities from existence (United Nations General Assembly, 2010). Unfortunately, not all countries have the economic resources or societal support to fully adopt these recommendations. Hence, millions of children globally reside in institutional care for many of their developmentally influential years (Petrowski et al., 2017).

Despite the research documenting the damage to children living in institutional care (CIC), children in these settings show heterogeneity in adjustment outcomes. While there is extensive literature documenting deficits and delays in CIC (Dozier et al., 2012), there are studies documenting normative or positive development among CIC as well (Mota & Matos, 2015; Salifu Yendork & Somhlaba, 2015). For example, a recent study (Wright et al., 2022) found that CIC in Ghana showed a number of different patterns of adjustment across the domains of academic achievement, anxious and depressive symptoms, and quality of life, ranging from below average to average functioning, when compared to the functioning of children in families (CIF) from the same geographic area. Additionally, the patterns of adjustment that emerged from quantitative analyses revealed that both CIC and CIF tended to do well in several areas, while struggling in one or two. The majority of the CIC met the criteria for being considered “resilient” in one or more areas, in that they performed at or above the level of adjustment demonstrated by their CIF peers.

These quantitative findings suggest that something different may be taking place in the institutional care context in Ghana compared to areas previously studied by institutional care researchers. The present study sought to understand how Ghanaian adults involved in child-rearing (those with the power to adopt new practices and interventions) conceptualized positive and negative child adjustment, what they perceived the predictors of better or worse functioning to be, and how they interpreted the findings from a previous study (Wright et al., 2022).

Ghanaian Context

Ghana has a population of around 30 million, with 10.7 million under the age of 18 (The World Bank, 2020; UNICEF, 2012). It was the first sub-Saharan country to establish democracy, and has maintained a multi-party democracy for decades. The capital, Accra, is an urban region along the coast, although the country includes several other vibrant cities and many rural communities as you move further inland. The Greater Accra region is home to approximately 5.1 million Ghanaians (Ghana Statistical Service, 2021). English is the official national language, but nine other recognized native languages are commonly spoken.

Ghana is categorized as a middle-income country and has successfully reduced its poverty rate by nearly half over the course of 15 years (UNICEF, 2012). However, approximately 28.5% of the population still live below the poverty line. In addition to high poverty rates, the country has also suffered through the HIV/AIDS epidemic. The adult HIV/AIDS rate is at about 1.8%, although higher among pregnant women and in certain regions of the country (UNICEF, 2012). In 2019, the country had an HIV infection rate of approximately 342,300, with roughly 20,000 new infections and 13,600 AIDS-related deaths each year (Ghana AIDS Commission, 2020).

Ghanaian culture often is described as being highly collectivistic as well as hierarchical, while placing immense value on family connectedness and respect for elders (Marbell & Grolnick, 2013). Although it varies in some regions, many parts of Ghana, including the Accra region, follow a patrilineal family descent system (Salm & Falola, 2002). Children are highly valued in Ghanaian culture, representing wealth and the continuance of family lineage, as well as the success of the parents’ marriage – something else highly valued within this culture. However, children are viewed as fragile and vulnerable, and therefore strongly protected (Salm & Falola, 2002). Within the family, a hierarchical structure exists, whereby elders are the most respected and viewed as the keepers of family tradition and knowledge. Children, in contrast, are valued but expected to respect the authority of adults and comply with instructions or requests without hesitation (Salm & Falola, 2002). Expectations for children vary by biological sex, with girls expected to perform more house-related chores and assist their mothers. Boys are given fewer chores, but expected to dedicate more time to their studies (Ampofo, 2001). This contributes to an educational attainment gap in the country, with boys attaining higher levels of education than girls. This gap widens as children progress further and further in school (Salm & Falola, 2002).

Religion is a principal part of Ghanaian culture. While Christianity has become the predominant religion practiced by Ghanaians, there are numerous other religions and spiritual practices present in the society, and religious freedom is highly valued (Okyerefo & Fiaveh, 2017; Salm & Falola, 2002). Outside of an explicit religious framework, the Ghanaian worldview tends to believe in a higher power and that individuals have a specific purpose or destiny to fulfill in their life. This sense of purpose combined with the strong value of community results in a drive to work hard for individual gains as well as community or national gains (Salm & Falola, 2002; Wilson Fadiji, Meiring & Wissing, 2021).

Institutional Care in Ghana

The combination of the moderately high poverty rate and the AIDS epidemic in Ghana has contributed to the high prevalence of orphans and vulnerable children in need of a home (4.7% of the total population) (Bettmann et al., 2017). Traditionally, orphans and vulnerable children are cared for through three practices in the Ghanaian culture (Ansah-Koi, 2006, Kuyini et al., 2009; Salifu Yendork, 2014). First, through the traditional inheritance system where a clan member is selected to inherit the property (if any) and the obligations of a deceased family member. The inheritor of the deceased relative is expected to care for the orphaned children left behind. Second, the system of crisis fosterage ensures that during crisis such as the death of a parent, children are placed in fosterage for continued care (Kuyini et al., 2009). Crisis fosterage doesn’t require close relatives of the orphan as community members can foster a child when the parent is deceased and when care by the surviving parent or family is unavailable or inadequate (Ansah-Koi, 2006, Kuyini et al., 2009). This practice is common among the Gonjas, a tribe in the northern part of Ghana (Goody, 1982) and in the Manya Krobo District in the Eastern Region of Ghana through the Queen Mother’s Orphan Care Initiative where some queen mothers volunteer to care for orphans within their district (Ansah-Koi, 2006). Third, marriage practices such as remarriage and polygyny also provide the avenue for orphans and vulnerable children to be cared for by step-parents after the death of a spouse. Research has shown that although these traditional systems of care for orphans and vulnerable children still exist and continue to provide care for many children in need of care, these systems have weakened due to factors such as poverty, rise in orphans from the AIDS pandemic and modernization (Ansah-Koi, 2006). The weakening of the traditional system of care for orphans and vulnerable children gave rise to the use of institutional care as an alternative care arrangement for such children in Ghana (Ansah-Koi, 2006). Nonetheless, Ghana has made great efforts to protect the wellbeing of their children. They were the first country to ratify the UN Convention on the Rights of the Child (CRC), have signed the African Charter on the Rights and Welfare of the Child, and have agreed to the recommendations set forth by the UN General Assembly Special Session on Children, titled “A World Fit for Children’ (UNICEF, 2010). Following concerns reported in studies about children placed in institutional care in Ghana such as corruption by orphanage administrators (Colburn, 2010), physical and sexual abuse (Ministry of Employment and Social Welfare & UNICEF, 2010), relationship problems between children and caregiver (Salifu Yendork, 2014) and poor psychological wellbeing (Adu, 2011; Kristiansen, 2009), the Ghanaian government has worked to deinstitutionalize the country, and prioritize placing children in family-based kinship care (UNICEF Ghana & The Department of Social Welfare of the Ministry of Gender, Children and Social Protection, 2017). Despite this, a recent audit conducted by the Ghanaian government documented that institutional children’s homes in the country still care for approximately 4,500 children (Quartey, 2013).

Currently, to obtain and maintain licensure to run an institutional children’s home in Ghana, an institution must apply for licensure and complete an annual renewal process through the Department of Social Welfare (DSW) (Quartey, 2013). Institutional care facilities who are registered and in compliance with DSW’s guidelines are required to have at least one caregiver for every seven children (Ministry of Employment and Social Welfare, 2010). Care is supposed to be arranged similarly to family-based care, with children living in small groups with a consistent caregiver who provides sensitive and responsive care. Physical punishment is prohibited and engagement in this activity can lead to staff dismissal or prosecution. A primary caregiver responsible for all major care activities (meals, homework, recreation, etc.) is assigned to each child, and secondary caregiving staff assist by completing household chores and providing support for the primary caregiver. Assistant caregivers step into the role of primary caregiver if the primary caregiver is not available, rather than relocating the children, in order to maintain consistency and familiarity for the group. All staff members must be at least 18 years old and at least four years older than the oldest child in care. Staff in management roles or who have sole responsibility for a child must be at least 21 years old. If caregivers do not have a professional degree relating to childcare, they must undergo a training by DSW. Institutions are required to maintain staff development and training opportunities (Ministry of Employment and Social Welfare, 2010).

A qualitative study on Ghanaian caregiver perceptions of care quality provided to CIC revealed that caregivers had significant concerns regarding the lack of adequate funding for essential items, lack of training, lack of supervision, and the lack of standards to ensure a sustainable care environment (e.g. staffing patterns) (Castillo et al., 2012). Of the 92 caregivers surveyed, less than half of them indicated that they had received training on caring for children. For those who had received training, the duration and content of the training varied drastically. Most of the participants also reported feeling so overworked that they could not give children the individualized time and attention that they believed the children needed. They also reported that children lacked a primary caregiver and continuity of care due to staffing patterns, which violates DSW’s standards for care (Ministry of Employment and Social Welfare, 2010).

However, qualitative interviews with CIC in Ghana have revealed that many perceive their lives to be better than those of CIF in the surrounding community (Lemons, 2010). Most children reported themes of feeling part of a family within the institution and feeling supported by their friends, within and outside of the home. Boakye and Wilson (2003) found that 90% of children in institutional care reported that they felt they were receiving adequate affection from their caregivers. Other studies have documented that, despite caregiver concerns about available resources, children in institutional care actually receive better education, nutrition, and health services than orphans who remained in family-based care in the community (Frimpong-Manso, 2014).

Family Care in Ghana

Family, both immediate and extended, is highly valued in Ghanaian culture (Gyekye, 1996). Children are raised to understand their identity within their network of blood relatives, and develop a strong loyalty to their parents and siblings. For parents, the ability to bear and raise children is seen as one of life’s main purposes, and children are regarded as their most prized possession. The Ghanaian culture emphasizes that children must develop good character, and therefore parenting focuses on passing on the values of society, and teaching kindness, respect, and manners. Parents believe that having a strong and positive relationship with their children is the key to teaching good behavior and keeping them out of trouble.

Summary

Through challenges faced by the country, Ghana has worked to build a support system for their many children in need of alternative care. This system extends beyond familial care to include institutional care facilities, which typically are thought of as detrimental to healthy child development. However, recent work suggests that the system of institutional care used in Ghana may not lead to patterns of child adjustment that vary drastically from those seen among CIF (Wright et al., 2022). Less is known about how Ghanaian adults perceive child adjustment across family and institutional care settings, and what factors they believe contribute to healthy development. Given that institutional child care in Ghana is an ongoing approach to care and seems to be associated with outcomes that are contrary to findings from other countries, the strengths and weaknesses of the system used in Ghana warrants further investigation, both to identify room for improvement and assets associated with the Ghanaian system that can be replicated elsewhere.

The Present Study

Based on recent work showing that the adjustment of CIC is heterogenous (Mota & Matos, 2015; Salifu Yendork & Somhlaba, 2015) the present study had two main purposes: (1) to understand adult perceptions of positive adjustment and predictors of better functioning broadly within institutional and family settings, and (2) gather key informant interpretations of findings from the Wright et al. (2022) study. A goal was to illuminate areas of intervention identified by Ghanaian adults, which may be adopted to further improve the care children receive in institutions and reduce the risk of negative outcomes. A qualitative approach using a multi-step process outlined by Merriam and Tisdell (2016) for grounded theory research was used to address this aim. First, this part of the interview provided insight into participants’ baseline understanding of child development, risk, and resilience, while also suggesting additional areas of adjustment, risk, and protective factors which may be relevant for future research. Second, caregivers’ and educators’ thoughts and interpretations of findings from a previous study (Wright et al., 2022) were assessed. The study investigated patterns of functioning for children in institutional care and children in family care in Ghana, across internalizing symptoms, quality of life (QoL), and academic achievement. Three patterns were identified for children in families, while four were identified for children in institutional care, with youth in three of the four patterns demonstrating functioning that could be considered resilient. Protective factors differentiated between the patterns, but in ways not hypothesized. Children’s self-efficacy, adaptability and persistence, social support, and various coping strategies were expected to differentiate between patterns. However, only problem-solving coping significantly varied between clusters of children in institutional care, while self-efficacy and adaptability and persistence differentiated between clusters of children reared in families. Due to the difficulty in interpreting these findings, the present study sought the interpretations of child-rearing professionals within the Ghanaian context to better understand these specific results. Additionally, we sought their feedback on the cluster analysis findings as a form of member checking for the Wright et al. (2022) study (Lincoln & Guba, 1985).

Method

Participants

Ghanaian public-school teachers (n = 19), institutional caregivers (n = 15), and institutional social workers (n = 4) (82% female; M age = 43.32, SD = 10.37, range = 26–63 years) were recruited from the schools and children’s homes in Accra, Ghana that had participated in the Wright et al. (2022) study. Teachers, rather than parents, were recruited to provide the perspectives on CIF due to their professional exposure to a vast number of children, and ability to observe patterns across them. Additionally, most (90%) of the participants were parents, so they were able to provide insight based on their personal and professional experiences. Purposive sampling was used to recruit a balance between teachers and institutional staff as well as a balance across age range and sex. However, caregivers were almost exclusively female, so the sample remained skewed in that direction. Forty participants initially were recruited. One individual opted not to participate after learning that interviews would be audio recorded, despite reassurance that the audio recording would not be linked to her personal information, and one audio file failed, resulting in interviews from 38 participants. Participants’ religious affiliation included Christian/Catholic (87%), Muslim (11%), or none.

To be included in this study, participants needed to be over the age of 25, to ensure that they were not a child resident of the institution during the original study; a full-time employee at one of the included children’s homes or schools; and have lived in Ghana for the majority of their life. Participants were excluded if they did not feel comfortable participating in the interview in English. All of the teachers had at least a teaching certificate, which is considered equivalent to an associate’s degree, and many had bachelor’s or master’s degrees. Seven of the caregivers at the children’s home had only completed middle school, while the rest had completed high school or tertiary certifications. The education of the social workers on staff ranged from bachelor’s to master’s degrees. On average, participants had worked in their current institution for over a decade (M = 10.24, SD = 9.72 years) and had over 17 years’ experience working with children (M = 17.45, SD = 9.03 years).

Measures

Demographics

A demographic questionnaire was completed by participants at the start of each interview. Questions included participants’ age, sex, educational attainment, religious affiliation, number of years living in Ghana, parental status and ages of children if applicable, number of years working at their current institution, current job title or role, number of years working with children, number of years working with children from a vulnerable population, if any, and which populations those were.

Semi-structured qualitative interview

The questions included on the semi-structured qualitative interview were developed following quantitative data analysis from a previous study (Wright et al., 2022). First, institutional staff and teachers were asked about their understanding and beliefs regarding child development, risk and protective factors, and positive adjustment among children residing within institutional settings. The interview included questions on the differences between adjustment of CIC and CIF, the areas of adjustment in which they see children thriving and struggling, questions assessing institutional staff or teacher beliefs regarding why or how some children adjust well to the institutional care setting or what has helped most with the adjustment and why other children have struggled to transition, and questions regarding the most helpful strategies or elements they have seen used to aid in a child’s positive adjustment within whichever setting they work. Then for the second part of the interview, participants were presented with a summary of the findings from a recent study (Wright et al., 2022) in basic language, and then asked a series of questions to assess their perceptions as to whether the patterns of adjustment found in the data aligned with their observations, how they explained certain results found for the differentiating factors explored, and any other areas of investigation they believed would be important for future research that had not been included in the current study.

Procedure

Following ethical approval of study procedures and associated documents from Virginia Commonwealth University’s IRB, the same four orphanages and two primary schools included in Wright et al. (2022) were contacted for permission to perform recruitment and data collection for the present study. The Ghana Department of Social Welfare (DSW) and Ghana Education Services provided approval for recruitment from these settings for the proposed data collection. Timing of data collection was scheduled so that it did not coincide with any official vacations in order to increase rates of institutional staff and teacher availability for participation. As a result, interviews were conducted within a three-week period between January and February 2019. Between the time of data collection for the Wright et al. (2022) study and the present study’s data collection, one of the children’s homes closed and another had recently experienced significant changes in staffing. In the end, recruitment for the present study was restricted to one of the original schools and one of the original children’s homes. Local collaborators confirmed that each of the included sites were representative of typical schools and children’s homes in the region.

Interviews were conducted by the first author, a US citizen, the second author, a Ghanaian developmental psychologist, and another local Ghanaian clinical psychologist. Both of the Ghanaian psychologists had collected the quantitative data on which the Wright et al. (2022) study was based. The research team met as a group prior to the start of data collection to review study procedures. Once all members were trained on the study protocol, the team visited each site on days and times indicated as convenient for data collection by the head teacher and head caregivers. Staff at each site were informed that researchers were present to conduct interviews regarding child development, and they were encouraged to approach one of the researchers to learn about the study if they were interested, at a time that was convenient for their work schedule. Researchers remained in a quiet location removed from the classrooms and offices to ensure participant privacy during recruitment and data collection. When a potential participant expressed interest, they were given a brief summary of why the study was being conducted and what participation would involve. Verbal assessment of inclusion criteria was then assessed, and informed consent was obtained. Interviews were then conducted and audio recorded. Length of interviews ranged from 20 to 55 minutes. All interviews were conducted in English to reduce the need for translation. Due to the first author’s foreigner status, she observed the first interview at each site conducted by the two local researchers to identify any participant questions that arose, how the interviewers answered or explained questions further, as well as the level of elaboration participants gave in their responses. The openness and level of detail given in responses then were compared to interviews conducted by the first author to determine whether her status as an outsider influenced responses in any way. No significant differences were identified when reviewing audio recordings and transcripts. The two local researchers also observed the first author’s interactions with participants and did not find that participants were altering their behavior or responses with her. It was therefore determined that the principal investigator could reliably conduct interviews. Participants were given the option to skip any questions they did not wish to answer or stop the interview at any time. They were compensated for their participation following completion of the interview.

Interview transcription and organization of responses

Table 1 outlines the steps taken as interviews were being completed. Transcription began in tandem with interviews. Each audio recording initially was transcribed by either the first author or the third author. Next, transcripts were checked by a second party to ensure that any initial transcription errors were corrected. The first author acted as either the transcriber or checker for every transcript. Once all transcripts were drafted and checked, the first author and the third author jointly pulled participant responses from the transcripts and organized them in a single file based on interview question, for ease of coding.

Table 1 Stages in the thematic analysis of interviews
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Data Coding and Analysis

The coding team included the first author, who has a history of experience conducting research in Ghanaian institutional care facilities; the third author, who at the time was an undergraduate psychology major with experience within Indian institutional care settings; and the fourth author, a developmental psychology graduate student at the time who is of Ghanaian background, has a master’s degree in human development, and has professional experience relating to child development within the Ghanaian cultural setting. Themes from the qualitative interviews were identified and evaluated in a multi-step process, as outlined by Merriam and Tisdell (2016) for grounded theory research. First, the team used open coding, whereby each coder separately reviewed answers to each interview question and recorded codes identified. When codes were identified more than once, participant ID numbers were recorded to keep track of frequency of a code. Once all three raters were finished coding the data independently, the process of axial coding was used to compare codes across raters in order to create a consistent label for each code, which represented the thought, observation, or experience being expressed by the participants. Discussions between raters were used to reach consensus when codes appeared similar but may have been recorded slightly differently. For example, when one rater recorded a code as “children have different strengths or abilities” and another rater identified the codes “children have individualized strengths and weaknesses,” it was agreed upon that these two labels represented the same overall theme.

Participants were recorded as having endorsed a theme if at least two out of the three coders independently identified the theme for that participant, though most often all three coders agreed. The endorsed themes were then evaluated to determine frequency across the sample, with top themes for each interview question selected. Common themes typically had a 20% or higher rate of endorsement across the sample, though sometimes themes were considered common if a subsample had frequent endorsement (i.e., 20% of teachers expressed a certain belief). Once common themes were identified, the demographic patterns of participants who endorsed each theme were explored. Themes and demographic patterns were reviewed by the second and fourth authors who each provided feedback on whether results appeared consistent with their perceptions of the Ghanaian cultural context. They provided further explanations and hypotheses when themes appeared discrepant from their initial expectations of results.

Trustworthiness

Multiple efforts were made to ensure the trustworthiness of the findings. The second author served as a cultural consultant through all aspects of the study design, conduction, and analysis. She provided insight into culturally appropriate language to use when drafting interview questions, served as the liaison between the first author and recruitment sites, oversaw interview processes to determine whether participants were responding in different ways with the first author versus other interviewers due to cultural differences, and consulted on the identification of themes while providing insight into why certain themes were revealed as most common. Other research team members of Ghanaian background were intentionally recruited to assist with data collection and coding, in order to not rely solely on the second author’s perspective. Three coders engaged in the coding and theme identification process for all participants. Team members met to discuss the coding process several times throughout this phase of the study. An audit trail was maintained for all transcription, coding, and theme identification (Lincoln & Guba, 1985). After themes from the three independent coders were summarized, the second and fourth authors both served as peer reviewers and provided feedback to ensure that the identified themes were consistent with Ghanaian culture (Lincoln & Guba, 1985). Further, throughout this manuscript, rich descriptions of the participants, context, and their interview statements were provided, so that the reader can evaluate the credibility of our conclusions (Creswell & Miller, 2000).

Results

The aims of this study were to illuminate adult perceptions of child adjustment within institutional care versus family care in Ghana, deepen the interpretation of results from previous work (Wright et al., 2022), and inform the direction of future intervention and research by identifying culturally salient areas of adjustment, risk, and protection. The varied perspectives of teachers and institutional care staff provided richness and context to many of the questions raised by the results of a recent study (Wright et al., 2022). Themes are summarized in Table 2. All participant names have been changed for the purpose of maintaining confidentiality.

Table 2 Qualitative themes identified
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Patterns of Functioning

When asked to describe the functioning of the children with whom they work, participants most commonly gave positive responses, indicating that, overall, the children they serve were doing well. When asked about specific patterns, the most common response was that each child has their own strengths and weaknesses. A teacher, Belinda, explained, “There are some who do well in all areas. Some, too, do well here, and there not. It’s [varied].” Participants repeatedly emphasized that even children who are struggling have strengths; for example, those who are behind academically are often highly social or excel athletically. Sarah, a teacher, reported, “It’s not everyone that has intellectual ability. Others, his is to draw, his is to dance; each and every individual has his own ability.”

Perceptions of Positive Adjustment

Across both institutional staff and educators, participants frequently described children who were doing well as those who were often happy, were well-behaved, showed consistent progression or improvement, were playful or active, and had a good quality of life including caregivers who were actively involved. Ishmael, a teacher, shared, “You see the parents, and the parents too they normally come here [to school] – [children] that are good – [their parents] will be coming, you see them. Oh, they will be taking very good care of them and they don’t need anything.” Similarly, Ama, a caregiver, explained, “Oh, if a child is doing well, you see him happy, playing. Any time you see him or he or she is happy and playing around. Oh, they are always cheerful. Uh huh – they are always cheerful.”

Teachers were more likely than institutional staff to describe these children as determined, enjoying a challenge, being hardworking, and performing well in school. Performing well included things like being punctual to class, always appearing willing to come to school, participating in activities or conversations, as well as having good handwriting. Ishmael provided elaboration:

You could see he’s having that zeal, or having that happiness in class because when a child [realizes that] the teacher likes him or her so much, the child is always willing to come to school. You never see the child absent from school.

Esther gave a personal anecdote:

So I gave them writing, and I was expecting the boy to finish first, and I see the boy and I ask why and he says ‘madam, this is writing and I have to take my time’ so the boy knows when to be quick and when to even take [his] time to get perfect work done.

Institutional staff were more likely than educators to describe children with positive adjustment as those who were cooperative or helpful. Joyce shared:

Sometimes she even helps her colleagues who are small, maybe if they fall and we [are busy doing] something then she helps them to get up. And she respects us. The little things we send her to do, she [does] it well.

Meeting developmental milestones on time and growing well or being healthy were reported exclusively by institutional staff. Akusua identified physical abilities as a theme; “When the person can walk, you see that he is walking. You see that he is doing well. They’re about to speak, too, they can speak.”

Perceptions of Negative Adjustment

Children who were not doing well were described by participants as those who were unsocial, timid, or bullied and who were often unhappy. Teachers frequently interjected that, although the children were struggling in some areas, they likely still had strengths in others. Teachers most often cited the example of children who struggled in class but excelled in sports. Joseph explained:

They may have interests in certain things also. Maybe that side, they might do well there – not only academically, you see? Somebody – I once taught a guy – the guy had a mental problem but if you go to football, the child is very good at goalkeeping.

Teachers focused heavily on academic success as the primary indicator of functioning. They also described struggling children as lacking motivation, having poor attendance, coming to school unprepared, being distracted in class, and having a poor quality of life. A lot of blame appeared to be placed on caregivers or the home environment for poor academic success; teachers often noted broken homes as the source of children’s poor adjustment. Lydia provided one instance of this:

But others, because of the background, the parental care is [lacking]. Some come from broken homes. Some, they have teenage parents, so it has affected them in their life all around. And there is nobody to give care at home.

However, these explanations were less common among institutional staff, who instead perceived poor functioning to mean developmental delays or having special needs. Their focus appeared to be more on physical health, growth, and the ability to interact with caregivers rather than success in school. Doris explained, “They can’t walk, or they can’t talk, can’t touch anything, [they’re] just lying down. [We are] always feeding them, changing them; they can’t do anything for themselves.”

Contributions to Academic Functioning

Throughout the entire interview, teachers’ responses focused predominantly on academic functioning, and had they shared extensive thoughts on what leads to better or worse functioning in this domain. This was likely due to academics being their area of expertise and the arena through which they have the most contact with children. Teachers were more likely than institutional staff to share beliefs that home environment, whether lack of resources or having all needs met, was a strong contributing factor to academic standing. Several teachers explained that when a child’s needs aren’t met, they often are preoccupied with thoughts relating to this during class, which distracts them from their work. Belinda stated that she observed:

[She] cannot concentrate in class. You will see [that she is] very quiet and always moody, you see. Those who are moody and sad, you see that there’s a problem from the home. Either broken home, some staying with their parents’ friends, some staying with their grandmothers. [The parents] don’t have time for them.

On the other hand, when all of a child’s needs are met, participants explained that they can focus on schooling. Plus, parents are able to provide the necessary educational supplies as well as supplemental materials.

Parenting and adult support were other factors frequently noted as contributing to academic success. Teachers believed that parents should provide encouragement and allow children time to focus on their studies; when they do not, children struggle through homework and cannot achieve at the same rate as their peers. Esi expressed:

I think when a child has been taken care of very well, you provide all the basic needs, you feed the child well, you buy the child textbooks and other things for them. When that child comes to school, that child is always happy to do his or her best, but when you are lacking parents to push you academically, you can’t perform well.

The final theme noted by teachers was the foundational education of children in combination with the current quality of their teaching. They described things like a teacher’s ability to tailor their teaching style to the needs of their pupils, a teacher’s education level, school resources, and the strength of a child’s education prior to that point as dictating how well the child would succeed in a given year. Selina explained:

And then, strategies used by the teacher; some of [the children], when you look at their level, you have to come down, down, down, but if the teacher doesn’t have the patience to come down to the level of the child, that one – the child – will never [understand the material] because he himself is [behind] already.

Institutional staff attributed academic success or difficulty to individual factors such as personality or IQ. They noted that lack of motivation can lead to poor academic achievement, while having discipline and being hard-working lead to success. Florence shared, “So, I believe that it is because the children are not motivated enough to be interested in academic work so [getting them to do] that becomes a struggle.” Teachers endorsed these beliefs at a similar rate to the institutional staff.

Contributions to Emotional Functioning

Relative to academic functioning, participants made fewer comments regarding factors leading to positive or negative emotional functioning. Both teachers and institutional staff believed that poor parenting and lack of adult support contributed to emotional problems in children, and that having a good home environment with all needs met led to more positive emotional functioning. Ruth, a caregiver, explained this in detail:

The emotional problems for children [come from lack of] love… Maybe the parents will be shouting at the children in the house. When he is going from school or going to the house the person will not be happy. Whenever he is going back to the house, that one too affects children.

Similarly, Edith, another caregiver, shared, “When mothers are there taking care of the children [and they are] always at their side helping them in so many things, [the children’s] emotions are very good.” Teachers were more likely than institutional staff to note poor home environments or lack of resources as contributors to negative emotions. Further, teachers often described difficult peer relationships or bullying as leading to poor emotional functioning, while adult support led to positive functioning. Henry reported:

If there is a quarrel between friends, you see, the child – anything the child do – emotionally he or she is not happy because he will be thinking about the friend ‘If I go out to break, who will I play with? Who will I talk to?’

Contributions to Quality of Life

Similar to the other areas of functioning, institutional staff and teachers alike identified good parenting and adequate support from adults as leading to better quality of life for children, while a poor home environment lacking in basic resources contributing to a lower quality of life. Isaac, a teacher, believed, “Everything boils down to the parents, if he is being taken care of in the house.” Abena, another teacher, emphasized that “A good quality of life is associated with proper treatment, proper upbringing, provision of the child’s needs.”

General Protective Factors

When asked broadly why children might perform better in one area or another, compared to their peers, participants reiterated themes noted previously. Individual factors, such as genetics or differences in personality were believed to set some children ahead from others. Home environment, having needs met, and the level of adult support present in a child’s life were all mentioned as well. Abena noted:

I could see that it depends on the child’s genetics. Like I said, some children, their parents are very brilliant… and some of them, like a child in my class, the parents are doing everything yet this one you can see that it’s something generic. Yeah, the child is given all the methodology, yeah. Others, too, it is because they are not getting what they need.

Interpretations of Previous Findings

Participants were presented with a summary and description of the quantitative findings from a recent study (Wright et al., 2022), and asked for their thoughts and feedback. One of the key findings from the study concerned problem-solving coping. For CIC, but not CIF, problem-solving coping varied significantly among the different profiles of child adjustment. CIC who reported high levels of depression and anxiety also reported using significantly more problem-solving coping than CIC who reported the best overall functioning. Participants provided interesting perspectives on this pattern of results – perspectives mentioned by both institutional staff and teachers, though more often reported by teachers. The participants explained that, in Ghanaian culture, children are not expected to solve their own problems; parents or adults are expected to solve problems for children. Dora, a caregiver, explained, “Oh, they can’t solve that problem by their own, they can bring it forward to a mother or a supervisor so that we can help him or her.” Therefore, CIF who have more adult support have not yet needed to develop the skill of solving their own problems. This is why it was not a significant differentiating factor for the adjustment profiles of CIF. The CIC, on the other hand, experience less support from adults due to higher child to caregiver ratios. Esi, a teacher, provided a summary of this belief:

Those in the school, their problems are being solved by their parents, they provide some of them, not all of them but their parents provide everything for them. So, whenever they have problem, they think their parents would [solve] it for them, but you know those children in the orphanage, they [don’t have] anybody. So, they have to be taken to counseling and taught on how to solve problems on their own.

When CIC encounter problems, they may not have adults available to solve the problem for them. They therefore are forced to develop this skill on their own and use it as a means of coping with hardship. The presence of this skill for some CIC allows it to be a significant differentiating factor among the various clusters identified.

When asked for their thoughts on other variables that contribute to adjustment, which had not been accounted for in our study, two predominant themes emerged. Participants frequently mentioned parenting quality or the level of parents’ education as a significant factor. Religion or spirituality was another factor, which primarily was endorsed by institutional staff.

Summary

The present study’s findings revealed that institutional staff and teacher perceptions of child adjustment and predictors of functioning were fairly consistent with each other, and supported the findings of past research (Wright et al., 2022). Most participants felt that, although children may struggle in one or more areas, they will have personal strengths in certain other areas. Overall, having all basic needs met, a stable home environment, and a high level of parental involvement or adult support were the most common factors believed to contribute to positive functioning across domains. Some noteworthy differences were that teachers primarily focused on academic successes or struggles, while institutional staff framed negative adjustment in terms of developmental delays or disabilities. Teachers were more likely than institutional staff to share beliefs that home environment and parenting were strong contributing factors to academic success and emotional adjustment.

Although clear themes were not identified in response to questions regarding self-efficacy and adaptability or persistence as differentiating factors that emerged from the results of recent research (Wright et al., 2022), an explanation for the problem-solving coping results was identified. Participants explained that in Ghanaian culture, children are not expected to solve their own problems – adults are expected to solve any problems a child will face. However, in institutional care, where the child to adult ratio is higher than in typical households, children may need to solve their own problems due to unavailability of adults to solve it for them. Therefore, these children are more likely to develop this skill, which makes it more likely to be a significant differentiating factor for CIC compared to CIF.

Discussion

Extensive research has documented the detrimental effects institutional care can have on children (Dozier et al., 2012). The field has begun to focus on examining healthy adjustment or resilience within this setting, and results from several studies have shown heterogeneity in the adjustment of youth in institutional care. One such study situated in Ghana found that CIC demonstrated a range in functioning, with many patterns aligning with patterns demonstrated by CIF (Wright et al., 2022). The present study was designed to contextualize and explain results from a recent study (Wright et al., 2022) within the cultural framework from which the data originated. The present study advanced the current literature by integrating the cultural values, beliefs, and perspectives of key informants into the interpretation of quantitative results. Frequently, studies of institutionalized children are conducted in one country by researchers from another (Gunnar et al., 2012; McCall et al., 2010; Wolff & Fesseha, 1999). This poses the risk of cultural bias when interpreting findings. Though bias can exist in many forms and in many phases of the research, the design used in this study was a step toward reducing bias in institutional care research, and illuminating a richer understanding of previous findings from the cultural context in which it originated.

Thirty-eight teachers, caregivers and social workers generously gave their time to discuss their perspectives on child adjustment within institutional care and family contexts in Ghana. They detailed their perceptions of variables that lead to better or worse functioning across numerous domains of child adjustment, for CIC and CIF. Their contributions provided rich elaboration to the quantitative findings from the Wright et al. (2022) study and helped explain results that seemed surprising outside of the Ghanaian context.

Most participants agreed that children can show varying levels of adjustment in different domains. Institutional staff tended to report that the children they worked with were doing very well. When they discussed the ways in which children struggle, they commonly perceived disability or developmental delays as the primary area of poor adjustment. It is possible that this is the area in which CIC show the worst functioning, or it is possible that this is a domain that caregivers are intimately familiar with, and more so than teachers. The rates of physical disability for individuals in Ghana are estimated to be between 7–12% (Tuakli-Wosornu & Haig, 2014). Due to limitations in accessibility, approximately 70% of children with disabilities in Ghana are not enrolled in school (Mprah et al., 2015), which would make caregivers more in touch with this area of difficulty than teachers.

However, it is also possible that the institutional staff did not want to disclose other areas of difficulty, not determined by genetics or pre-institutionalization circumstances, due to concerns for how this would reflect on the care the institution was providing. Some participants inquired about the confidentiality of their interviews, which may have been out of fear of retribution from administrators if they painted the facility in a negative light. Another possibility is that staff may have opted to focus on positive elements of adjustment in order to avoid playing into the stereotypes that children in care are struggling, or have poor adjustment. There is nearly a century’s worth of literature citing devastating developmental outcomes associated with institutional care, which perpetuates the public narrative that these care facilities are detrimental to children (McCall & Groark, 2015). Given the cultural tendency in Ghana to hold a high level of national pride (Salm & Falola, 2002), and have a strong desire to lift up the greater Ghanaian community, it is possible that they wanted to focus on the positives in order to align with this cultural value. Of note, the level of positivity in responses did not seem to vary based on interviewer, so this positive lens does not appear to be due to differences in comfort disclosing difficult circumstances based on “insider” or “outsider” interviewer status.

When talking about functioning broadly, teachers deferred to talking about academics and provided more elaborate responses when questioned about academics versus other areas of functioning. This is understandable, given that academic functioning was their area of expertise and the arena in which they had the most interactions with children. They still provided detailed and valuable responses to questions about other domains, but required more specific prompting to discuss those areas compared to the institutional staff. It is possible that this tendency to gravitate toward discussion of academics also was due to a strong value for academics. Ghanaian culture highly values academic achievement, as individuals understand that education opens up numerous financial and professional doors for individuals and by extension, their families (Chowa et al., 2013).

Across various interview questions regarding functioning and predictors of adjustment, caregivers were less likely than teachers to report home environment as a factor. It is possible that caregivers did not want to insinuate negative things about the facility they worked in, out of pride for their work or possibly fear of repercussions from administrators. Some caregivers appeared guarded in their responses at times, demonstrated by providing briefer responses to questions regarding negative functioning. However, some participants disclosed strong feelings that the institution was under-staffed for the number of children living there. This theme was endorsed by staff at all administrative levels within the institution, indicating it was not only caregivers who felt this way.

The explanation of children not being expected to solve their own problems as why problem-solving coping was not a significant differentiating factor for the CIF sample in the Wright et al. (2022) study was one of the biggest revelations from this study. The CIF clusters all experienced similar rates of problem-solving coping, while the CIC sample showed significant variation. Caregivers explained that CIC have fewer caregivers to solve their problems for them, so are more likely to need to develop this skill than are CIF. This aligns with the cultural perception of children as fragile and vulnerable, and needing protection from family (Salm & Falola, 2002). This is also highly consistent with the hierarchical nature of the culture, which perceives children to be in a position of deference to adult advice, wisdom, and support.

Intervention Implications

One goal of this study was to illuminate areas of intervention which can further improve the care children receive in institutions, so as to reduce the risk of negative outcomes. Previous international intervention efforts within institutional care have targeted a range of bioecological model levels (Wright et al., 2019). Interventionists have aimed to teach skills to individuals, alter environmental contexts, and change microsystem-level factors such as caregiver responsivity. Given the predominant theme that adult support and care context matter most, it seems appropriate to recommend that interventions within Ghanaian institutional care facilities focus on the micro or macrosystem levels, rather than the individual level. Previous literature describes Ghanaian culture as encouraging interdependent living, whereby the wellbeing of all members is valued and fostered through social harmony and supportive efforts (Opare-Henaku & Utsey, 2017). Staff, caregivers, and administrators within the institutional care settings would likely show higher rates of buy-in and dedication to interventions aligned with this collectivist view, such as increasing the number of staff available to support children, increasing the education levels and wellbeing of caregivers, or improving care practices.

Further, a consistent message from nearly all of the participants was that stability of home environment and having all basic needs met is one of the most important factors. Before intervening in any other areas of the child’s life, programs or agencies targeting improvement in care within institutions should make provision of basic needs and stability in caregivers or home environment the first priority. It was participants’ beliefs that children cannot grow or show improvement in academics or emotional functioning if the basic standards of a good quality of life are not met. This view is consistent with Maslow’s hierarchy of needs, which suggests humans require that physiological and safety need be met before advanced development can take place (Maslow, 1970). Other studies have supported this theory, documenting that intervention to areas of basic need such as nutrition or stable, safe care environments leads to improvement in child psychological wellbeing or academic achievements (Berument, 2013; Faught et al., 2019).

Strengths, Limitations, and Future Directions

The present study has many strengths, as well as several limitations. The qualitative design was a strength in that it allowed for a rich analysis of adult perceptions of child adjustment in Ghana, and gave a culturally-informed interpretation of findings from recent research (Wright et al., 2022). The sample had the benefit of interviews provided from participants in two contexts (schools and institutional homes) which allowed for the collection of a range of perspective and conceptualizations of child adjustment from participants across different backgrounds. Further, the team of researchers involved in the various stages of the project included members of a variety of cultural backgrounds and experiences with CIC. This was a significant strength in that it allowed for multiple perspectives, ideas, and interpretations to be discussed and integrated into the final product.

Despite these strengths, it is important to discuss the limitations of the project as well. One of the most prominent features of the study design was the PI’s cultural distance and differences from the population being studied. To address this issue, cultural differences were carefully considered at each stage of project development. The PI was involved in interviewing participants, and although it appeared as though participants were not responding differentially to the PI than to Ghanaian interviewers, they were aware that their answers were contributing to a study being conducted by a team that included foreigners. Participants may have presented their beliefs in a more positive light, knowing that they would represent the functioning of their nation’s children to a global audience.

Clear measurement of environmental characteristics in institutions as well as family homes should be included in future studies to determine whether CIC have equal or more resources than their CIF counterparts. Caregivers noted on occasion that the CIC were reluctant to leave the institutional home due to acknowledgement that they were receiving more resources and better care than they may have access to if they were in the general neighborhood context. The institutional homes have the benefit of receiving donations from volunteers and charitable organizations, which caregivers believed set them above the neighboring family homes in terms of resources to offer the children. This belief should be tested empirically before drawing any conclusions. It is possible that the children in Ghanaian institutions appear to be functioning fairly well compared to their peers due to both environments having approximately equal resources. Of note, the level of outside resources and donations may vary based on urban versus rural location of an institution. The current sample was selected from an urban location, and therefore may not reflect the experiences of those in more rural institutional or family contexts.

Conclusion

The purpose of the present study was to explore adult perceptions of child adjustment within institutional or family care in Ghana. Further, the study sought to identify adult perceptions of predictors of positive adjustment. Lastly, the study assessed adult interpretations of the child adjustment results found in a recent study (Wright et al., 2022). Qualitative interviews illuminated the collectivistic nature of Ghanaian values, as well as the importance for children of having family, or the support of strong, capable adults. Future studies and any intervention efforts targeting improved outcomes among CIC need to hold this cultural perspective in mind in order to gain buy-in from key stakeholders. This study is one step among many in the efforts to understand child outcomes in alternative care settings, and to inform how best to meet children’s needs when institutional care is the only option.