Pakistani orphanage caregivers' perspectives regarding their caregiving abilities, personal and orphan children's psychological wellbeing

Abstract

Background

Pakistan is home to 4.6 million children who have been orphaned. Limited data on caregiving in orphanages suggests that caregivers do not have specialized training and experience heavy workloads and high‐stress levels. Supporting these caregivers to provide responsive and consistent caregiving can improve their well‐being along with the psychological and physical development of children who have been orphaned. This research explored the main caregiving‐related challenges faced by caregivers in orphanage settings, their professional and personal needs and perceived emotional and behavioural problems manifesting in children under their care.

Method

This research adopted a qualitative research design with a thematic analysis approach. Semi‐structured interviews were conducted with 14 caregivers who were currently caring for four to 12‐year‐old children in Pakistani orphanages.

Results

Five main themes: (1) religiosity, (2) economic relief, (3) caregivers' needs and well‐being, (4) caring for children who have been orphaned and (5) need for context specific training, emerged from the data, which included several subthemes. Findings revealed the presence of positive religious views regarding the upbringing and care of children who have been orphaned. Work‐provided accommodation was an important economic relief. Caregivers' psychological, physiological and personal lives were affected by job‐related stress and demands. Many helpful and unhelpful parenting practices were documented, and challenges such as children's verbal and physical aggression, stealing, non‐cooperation and poor social skills were reported. The main professional issues included low salary, high numbers of children in care and lack of context specific professional caregiving training provided.

Conclusion

This study established the need for a tailored programme that suits the context specific caregiving needs in Pakistani orphanages to support the training and professional growth of caregivers and promote their wellbeing along with positive developmental outcomes in the children under their care.

Key messages.

• Job‐related stresses and demands affected all areas of the life of caregivers within the orphanages.

• The importance of religious beliefs regarding orphans' upbringing and care was an important positive aspect.

• Caregivers perceived numerous psychological and behavioural problems of the children in their care and used both effective and ineffective caregiving strategies in response.

• The main professional issues identified by caregivers included long shifts, low salaries, high ratios of children to carers and lack of professional training.

• There is a demand for training programmes that are context‐specific, focus strongly on the needs and support of caregivers working in orphanages and enhance their caregiving skills to strengthen child‐caregiver relationships and improve developmental outcomes in the children under their care.

• In response to this, orphanages should consider a structure that provides ongoing professional support and training in terms of the job description and caregiving skill enhancement for their staff.

1. BACKGROUND

Pakistan has a population of 200 million including 65.3 million children under the age of 14 years. Over 4.6 million children are orphans (Mahmood et al., 2020). There are several reasons for this large population of orphans. One primary reason is that the expense of education, medical facilities and even necessities like food and shelter are often unaffordable as many families have limited financial resources and inadequate living conditions. As a result, families are compelled to admit their children to orphanages where they receive food, shelter, medical facilities and education (Latif et al., 2016). Other common reasons are the death or divorce of parents and when children are born to unwed parents. The existing culture in Pakistan discourages the adoption of orphans as they are considered a financial burden, and an outsider, and thus, orphaned children rely on state or private charity organizations (Lassi et al., 2011).

Orphanage care is often characterized by a profound lack of caregiver–child interactions (Aqeel et al., 2019; Lassi et al., 2011) and driven by structural constraints such as long work shifts, high caregiver‐child ratios and insufficient training (Akram et al., 2015). This extended exposure to stressful work conditions predicts work role uncertainty, personal and professional dissatisfaction and internal conflict among caregiver professionals (Govindshenoy & Spencer, 2007). The link between working in a caregiving profession and high stress, emotional exhaustion, depression and burnout has been reported in many countries including the United States (Irenyi et al., 2006; Molnar et al., 2001; Putnam‐Hornstein et al., 2011), India (Singh et al., 2012), Hong Kong (Slack et al., 2011), China (Li et al., 2011), Turkey (Hermenau et al., 2015) and Greece (Ormel et al., 2013).

Due to stress, high workloads and lack of training, caregivers often resort to coercive strategies (Bromfield et al., 2010; Douglas, 2006; Goldman et al., 2003), which leads to a reliance on ineffective caregiving practices as a way to discipline or control children (Crouch & Behl, 2001; Lakhdir et al., 2021; Potten, 2015). Similar phenomena have been found in longitudinal studies showing how stress leads to the use of ineffective parenting practices, and negative child and parent outcomes (Akram et al., 2015; Kaufman et al., 2019; Li et al., 2011).

These issues have been consistently linked to poorer developmental outcomes for children (Bagby et al., 2008; Hermenau et al., 2015). Experiences of negative caregiver–child interaction and harsh parenting can result in developmental delays in physical growth, cognitive abilities, language, attachment and emotional maturity, as well as behavioural issues (Hermenau et al., 2015; Mackenzie et al., 2011; Molnar et al., 2001). In Pakistani orphanages, there is a high prevalence (50%) of behavioural issues (Lassi et al., 2011) and diagnosed psychological issues (63.8%) (Akram et al., 2015). These adverse outcomes of institutionally reared children have been attributed to the failure of orphanages to provide the necessary experiences of early childhood, such as sensitive and responsive caregiving (Çatay & Koloğlugil, 2017; Gilbert et al., 2009; Warner et al., 2017).

Close and dependable emotional connections between caregivers and children who have been orphaned can be a significant protective factor (Alem, 2020; Forston et al., 2016). Higher quality caregiver–child relationships are associated with better outcomes in children's psychological growth and development (Begle et al., 2010; Black et al., 2001; Dubowitz et al., 2011; Huynh et al., 2019; Warner et al., 2017). Many recent studies in orphanages also reported positive effects of context‐specific interventions and staff training that helped to create a warm caregiving environment built on the basic principles of at‐home care, supported positive relationships and quality interactions between caregivers and children and enhanced developmental outcomes in orphaned children (Berument, 2013; Ghera et al., 2009; Isnaeni et al., 2021; Kaur et al., 2018; Mohammadzadeh et al., 2017).

Although research has focused on the wellbeing of caregivers (Darkwah et al., 2017; Gallart & Matthey, 2005; Holzer et al., 2006; Irenyi et al., 2006), only limited research has recognized caregiver well‐being as an area of concern for the development of children who have been orphaned (Çatay & Koloğlugil, 2017; Freisthler et al., 2006; Gilbert et al., 2009; Govindshenoy & Spencer, 2007; Hermenau et al., 2015; Warner et al., 2017). Even though interactions with caregivers seem to be central to children's well‐being (Huynh et al., 2019), there has been insufficient research on factors related to caregiving practices in institutions (Forston et al., 2016). The views of caregivers are rarely explored by researchers (Irenyi et al., 2006). This brings us to Pakistan, where, until now, there has been no research done to explore the context specific needs of the caregivers in orphanages and their views regarding the delivery of evidence‐based training.

1.1. Aim

Given the unmet need for support and training among caregivers working in orphanages, it is important to ensure views are sought to develop and test effective support packages. This study aimed to examine the challenges caregivers face on a day‐to‐day basis regarding caregiving of children within orphanages; gather knowledge about their caregiving practices and confidence in their abilities to deal with children's emotional and behavioural problems; explore the extent to which job‐related demands affect their personal well‐being and describe areas of need for context‐specific professional support in order to be optimally effective in their caregiving roles.

2. METHODS

2.1. Design

This research adopted a qualitative design involving in‐depth interviews.

2.2. Participants

Fourteen caregivers were recruited through purposive sampling, from three orphanages in Lahore, Pakistan. To be included, participants had to be currently working as a caregiver of four to 12‐year‐old children in an orphanage (orphanages do not admit children younger than 4 years and the needs of teenagers are different to those of younger children). There were 687 children across the three orphanages (32, 184 and 471, respectively) with 20 caregivers (3, 5 and 12, respectively). Of the 20 caregivers, six were ineligible (as they looked after teenagers exclusively), and 14 were eligible and agreed to participate. Participants' age ranged between 27 and 51 years, all of the male caregivers had masters' qualifications while four female caregivers had high school education and two female caregivers had masters' qualifications. Caregivers worked in pairs during shifts of 10–12 hours daily, alternating between day and night duties. Orphanages provided accommodation to all caregivers and their families, along with free utilities, food and education for their own children. The caregivers were responsible for general upbringing, grooming and providing schoolwork assistance, making them a parent figure for the children in the orphanages. Participant demographics can be seen in Table 1.

TABLE 1.

Participant demographics

Participant ID	Gender	No of years working in the orphanage	Professional training received
17‐002	Female	>15	No
17‐003	Female	>15	No
17‐004	Male	6–10	No
17‐005	Male	>15	No
18‐001	Male	6–10	No
18‐002	Male	6–10	No
19‐001	Female	>15	No
19‐002	Female	>15	No
19‐003	Male	<5	No
25‐001	Female	<5	No
26‐001	Female	<5	No
30‐001	Male	>15	No
30‐003	Male	11–15	No
30‐004	Male	6–10	No

2.3. Procedure

Ethical clearance was granted from The University of Queensland's Human Research Ethics Committee (Approval number 2019001861). Permission to conduct the research was sought in the form of gatekeeper letters from the heads of all three orphanages. Caregivers were approached face‐to‐face in a private room to discuss the research. Participant information sheets were provided, including permission to audio record the interviews and outlining the right to withdraw at any time. Following informed, written consent, interviews were conducted one by one in person and audio recorded for later transcription. One interview lasted for 28 min, while the remained were between 45 and 65 min. All 14 interviews were conducted by the first author who is a Pakistani citizen and brought up in the same language and culture. Her stance was one of both an insider by being a Pakistani national and an outsider by conducting research through an institute outside of her home country. This dual positioning allowed her to have a diverse outlook on the study. Interviews were conducted and transcribed in Urdu, the national language of Pakistan, so that the nuance of participants' descriptions and narratives could be retained (Al‐Amer et al., 2015, 2016).

2.4. Interview protocol

A semi‐structured open‐ended interview protocol was used (see Table 2).

TABLE 2.

Semi‐structured interview

What is your job title? How long have you been working in this role? Are you financially satisfied with your job? What are your responsibilities in this role? What are the challenges you face in your role as a caregiver? Have you received any formal training for this role? Are you satisfied with your role? How would you describe yourself as a caregiver? How would you describe your caregiving capabilities? What do you like best about your job? What do you think your needs are as a caregiver of these children? Do you believe these needs are being met? Do you think children in the orphanage have emotional and physical needs? What do you think children at your orphanage need from you? What are some of the common behavioural and emotional problems shown by the children in your care? How do you manage these emotional and behavioural problems? How confident do you feel in dealing with behavioural and emotional issues/problems of these children? Is this role affecting your physiological or personal wellbeing? Please specify if it's affecting you in any other way also What are your major concerns related to the caregiving domain? Do you believe you have adequate training to deal with these emotional and behavioural problems of these children? What do you believe makes your job stressful? What do you do to deal with job‐related stress? Do you have an adequate support system? If yes, then please specify. What sort of training do you believe would be more useful to help you with your role? In which areas would you need more assistance or training to deal with caregiving issues? What are your suggestions for the training programme, which areas to be included and put more emphasis on? Would you like to tell me anything else? Would you like to ask me anything?

2.5. Analysis

A thematic analysis approach (Braun & Clarke, 2006) was used as it enabled in‐depth information about the lived experience of the orphanage caregivers to be captured. An inductive, bottom‐up approach was used to extract themes. Analysis followed a semantic rather than latent approach, describing what participants said and using this to arrive at interpretations (Braun et al., 2019).

Only the verbatim quotes included in this manuscript were translated into English.

To support the rigour and trustworthiness of the analysis, two coders conducted the data analysis. The first author and a second coder manually completed the entire transcription separately. The second coder was also a Pakistani citizen, with 4 years of experience in qualitative research. Both coders read and reread the entire data set independently, which resulted in complete coding. Consistent patterns across the data set were identified, generating possible codes, searching for emergent themes, reviewing these themes and defining and synthesizing these into major themes. Reflective discussions between the coders resulted in adjustments until no new codes, themes or information were identified.

Illustrative verbatim quotes from the raw data set were extracted, translated into English and presented against the themes to guarantee that themes adequately represented the verifiable meaning of the raw data. Themes were then re‐assessed against the entire un‐coded data set, separately by both the coders to ensure the originality and accuracy of reported content and analysis of the findings. All transcripts were labelled using a numerical code to protect the identity of the participants.

3. RESULTS

Five main themes emerged from the data: religiosity, economic relief, caregiver well‐being, parenting of orphans and need for training.

3.1. Theme 1: Religiosity

The first theme consisted of religious beliefs and values in relation to the caregiving role, which was reported by all 14 caregivers. There were two subthemes.

3.1.1. Faith in God

Religiosity played an important role in terms of job satisfaction. Caregivers reported they were content with their role despite the hardships and stress, because of their strong belief in God's purpose for them:

God has put me to this job so that I can serve them [orphans] and this service will lead me to heaven in the afterlife. I am earning my place in heaven by helping these children. (17‐002, female, >15 years' experience)

Religion teaches me to be nice and kind to anyone, these orphans for sure are very much in need of our love and care and caring for them is like making God happy and if He is happy then my life's purpose is all done. (25‐001, female, <5 years' experience)

3.1.2. Orphans as a source of blessing

Caregivers also saw the children as a source of luck and blessing:

I think about these things, that if I have survived something bad in everyday life or the bad luck that was supposed to come my way but did not; is because of these children, they pray for us, and believe me, prayers of orphans have very much power. (18‐002, male, 6–10 years' experience)

So much stuff has happened in my life that I am not sure how I have survived through that, but one thing I am sure of is, it's all the prayers and blessings of these children that are keeping me safe. (30‐004, male, 6–10 years' experience)

3.2. Theme 2: Economic relief

None of the caregivers were financially satisfied with their salary. However, this was offset by all the orphanages providing rent‐free accommodation, food and utilities, which kept caregivers in their positions.

None of us gets enough money, if we did not have this free accommodation and food, I do not know how it was possible to manage things. (30‐001, male, >15 years' experience)

If you just look at the salary without accommodation and utilities, there is no way I can take care of my family in this, this is not enough for us. (19‐002, female, >15 years' experience)

3.3. Theme 3: Caregivers' needs and well‐being

This theme captured personal and professional needs, significant caregiving challenges, personal well‐being and reported coping mechanisms of caregivers.

3.3.1. Personal and professional needs

Needs identified by all caregivers included a desire for increased salary, some form of professional training, more caregivers being hired and increased acknowledgement from the administration. All participants strongly believed that these needs were not currently being met.

We think that they [administration] need to increase our salary and hire more caregivers. At least they should praise us more, they know how much effort we are putting in, we will feel much better if they just praise us more. (19‐001, female, >15 years' experience)

I believe an increased salary would solve our many personal issues such as daily expenses. Other than that, we need some kind of training which can tell us how to do things right. (19‐003, male, <5 years' experience)

3.3.2. Caregiving challenges

All caregivers reported caregiving to be physically challenging and mentally tiring. The most common challenge was taking care of large numbers of children who come from diverse backgrounds and have already seen hardships in their families of origin.

We have a lot of kids here, taking care of this large number is stressful most of the time and we really struggle on a daily basis to handle everything. (17‐005, male, >15 years' experience)

These kids have seen so much worse, they are more difficult to handle, I have to be very careful regarding what to say and what not to say as I do not know what will put them off. (26‐001, female, <5 years' experience)

3.3.3. Physical, psychological, personal and social stressors

Shifts were long and the ratio of children per caregiver was high. Most (11) caregivers reported that they were sleeping less than 6–7 hours a night and worked continuously without taking enough breaks and that this was affecting their well‐being. No serious physical illness was reported by any caregiver.

It is a hard job, a very hard job to be honest, we do not have a normal eight hours sleep routine at home and even cannot go to the toilet without them [children] calling my name, it's a physically tiring job, my body hurts all the time. (17‐003, female, >15 years' experience)

We work in pairs for most days to handle all the responsibilities but sometimes even we both get tired because we cannot sit down for 10‐15 minutes without someone interrupting us, and when my shift finishes, I just want to sleep and lay down. (30‐001, male, >15 years' experience)

3.3.4. Gender difference in well‐being

Male caregivers reported more financial stressors and were generally satisfied with their physical and emotional health. All of the female caregivers reported that their job was affecting them psychologically in the form of stress, physiologically in the form of running out of energy, emotionally feeling drained and exhausted and personally as they were unable to find productive time to spend with their family or on their own.

When I go back after getting free from work, I just lie down either on the couch or on the bed. My own kids ask me to talk to them or go out for a walk, but I am too tired, my husband also complains that I am exhausted all the time but I just want to sleep. (19‐002, female, >15 years' experience)

Only three of the eight males reported that their job was affecting their physical and mental wellbeing.

No, I do not like it when I have to repeat one thing again and again to these children, so it makes me angry that they are doing it on purpose to tease me. (18‐001, male, 6–10 years' experience)

You know what exhausts me is when I cannot take a break even when I want to, because there is so much going on and then it upsets me and I just want to go back in my room and relax. (17‐004, male, 6–10 years' experience)

However, there was also a perceived positive influence of the job on the mental health of all female caregivers.

Kids make me feel important, one time I was sick for three days and when I was back, they all came running to me, they were hugging and telling me how much they missed me, it really makes me happy that I am so important to them. (17‐003, female, >15 years' experience)

3.3.5. Coping mechanisms

The most commonly reported coping mechanisms to deal with job‐related stress included praying, having a nap, talking to family/friends over the phone, having tea or warm milk, playing with children and chatting with other caregivers. Peer support worked best for caregivers as they could rely on each other for managing and dividing duties.

When we get tired, we just make jokes and try to make each other laugh, we sit together when kids go to school, have a cup of tea together and just talk our heart out over whatever is bothering us, we all help each other out, that's how this is still going on. (19‐001, female, >15 years' experience)

When kids are at school, we both sit down and discuss the daily problems with each other, sometimes if I have some personal work to do, he [another caregiver] covers the shift for that time and then other times I do the same for him. It really helps us. (19‐003, male, <5 years' experience)

3.4. Theme 4: Caregiving for children who have been orphaned

This theme covers the general caregiving attitudes of caregivers towards the children in their care.

3.4.1. Self‐perception as caregivers

All caregivers described doing things that are in the best interests of children in their care.

I am trying my best to give them (orphans) as much love, time and care as I can, but you tell me can anyone take the place of your own parents? Same is the case here, and they would always feel a gap that no one of us can fulfil. (17‐005, male, >15 years' experience)

Whenever I have to do something for these kids, I always think what is the best way to help them. I try to put these kids above my own needs and do what makes them happy so they feel at home here. (25‐001, female, <5 years' experience)

All caregivers considered themselves to be parents to the children. For example, female caregivers encouraged children to call them ‘Ami’ (Urdu word for mother) instead of ‘Aaya’ (Urdu word for caretaker/nanny), as it gave children comfort.

I specifically tell all the kids to call me “Ami” and not “Aaya”, I told them; now I am your mother, I am here for you in all good and sad times so you should come to me and do not feel sad over being away from your families. I believe it makes them [orphans] feel good. (25‐001, female, <5 years' experience)

3.4.2. Awareness of children's psychological needs

All caregivers acknowledged that they were fully aware of children having emotional, psychological, social and physical needs. They noted that the orphanage provides children with residential, educational and health facilities but there is still a gap. There was no psychologist in any of the orphanages because of financial constraints.

Look, right now we do not have sufficient funds, sometimes we have to buy some stuff from our own pocket. Now you tell me how we can afford a psychologist's fee or salary. (17‐004, male, 6–10 years' experience)

The most common behavioural and emotional problems reported by caregivers were stubbornness, lack of interest in studies, non‐cooperative attitude, crying spells, withdrawn behaviour, poor social skills, use of abusive language, hitting others, throwing or destroying things, lack of hygiene, stealing, not following routine, lack of confidence and poor etiquette.

Female children were perceived to be more cooperative compared to male children, who showed more hostility, physical and verbal aggression towards caregivers and other children.

Girls are good, they are easy to handle and listen to all of us more, but these boys are the ones who always have more complaints from school. They feel angry and sad inside that they [their families] have left us [orphans], they do not want us anymore. (25‐001, female, <5 years' experience)

Caregivers used different ways to manage these common behavioural and emotional problems, such as mutual discussion with children, playtime, telling religious and moral stories, phone calls or arranging meetings with family/relatives, encouraging positive behaviours, inducing fear of authority figures, stopping pocket money and time‐out.

You know, the best way I have found is to give them love and talk to these children and listen to what they are saying, then they think that we are giving them the importance and then they cooperate. (19‐003, male, <5 years' experience)

Sometimes when children do not listen, I do induce fear that I will tell the headmaster and he will stop your pocket money; then they listen very much. (30‐004, male, 6–10 years' experience)

The administration has allowed and encouraged any living parent or family member to come and visit these children, you know it gets so lonely if you are not meeting your own blood, we ask them to call them weekly at least if they cannot come. (19‐002, female, >15 years' experience)

3.5. Theme 5: Need for training

None of the caregivers had received any professional training for their role but became proficient by trial and error and taking guidance from senior caregivers. They all expressed interest in professional training.

We are doing our best but if you ask me if I am as best as someone who has some sort of training then I would say no, obviously I do not have that specific knowledge that you people have through your degree and studies. (17‐005, male, >15 years' experience)

Caregivers believed that having one training programme, attended by all caregivers, will help them to be on the same page and would enable them to feel more competent and satisfied.

You know this [training] could really help us, like all of us: kids, orphanage administration and us workers. Finally, we all will agree on one thing because I want to do better so I can be happy and not so stressed all the time and I might also get a raise. (18‐001, male, 6–10 years' experience)

3.5.1. Main areas of training needs

Significant needs and concerns included: the need for knowledge regarding caregiving of children, especially in stressful situations; how to gain children's trust; how to encourage children to be more cooperative; to understand developmental and psychological needs of children; managing temper tantrums and developing better communication skills.

We need help with managing their anger, these kids are angry most of the time, when we tell them to study or tell them that playtime is over, they do not comply. (18‐002, male, 6–10 years' experience)

They [orphans] do not know how to talk properly, I mean if someone comes to visit the orphanage, they just hide behind each other, their teacher even reports the same problem that they do not participate in class discussion although I know that they have done the work and they know the answers. (30‐003, male, 11–15 years' experience)

We all here want a training program that can tell us what we are doing wrong, honestly, we need that because no one ever gave us any sort of training, we want to learn how to help these children with everything, maybe if they [orphans] do right we [caregivers] can relax too. (19‐001, female, >15 years' experience)

You should train us in taking care of these children, I believe some professional training is better than no training at all, maybe if we improve ourselves after the training, they [children] might also start to improve and talk to us about their issues rather than fighting and yelling. (26‐001, female, <5 years' experience)

4. DISCUSSION

This study focused on exploring the perspectives of caregivers working in Pakistani orphanages. The main day‐to‐day caregiving challenges faced by caregivers were children's lack of social skills, low confidence, poor communication skills, non‐cooperative and aggressive attitude towards others and poor manners. These findings are in line with prior research in Pakistani orphanages, which showed that institutionalized children often exhibit more emotional and behavioural problems (Akram et al., 2015; Lassi et al., 2011).

Caregivers reported both positive and ineffective caregiving strategies. Harsh parenting practices are a societal norm in Pakistan (Alvi et al., 2017) and parents consider it their religious duty to discipline children even by force and punishment (Zaman, 2013). However, this is of concern in orphanages where children do not necessarily have protective family bonds, and it is the focus of this research to support caregivers to develop non‐punitive caregiving strategies.

Several personal and professional stressors were reported by all caregivers, such as high workloads, insufficient staffing levels, low pay and lack of personal time. These reports were consistent with the findings of previous research, which links caregiving with high levels of physical and psychological stress and illustrates how these stressors negatively impact the wellbeing of caregivers (Clément et al., 2016; Hermenau et al., 2015).

Consistent with Darkwah et al. (2017), caregivers' faith and intrinsic motivation was the most common coping mechanism to deal with work‐related stressors. Gender differences were observed in terms of caregivers' reported well‐being. This may reflect Pakistani culture which allows and expects women to be fragile and emotionally vulnerable when it comes to handling stressors (Khurshid et al., 2018). Interestingly, male caregivers only reported financial stressors. While it is possible that they did not experience physical or personal impacts of their caregiving role, it may also be due to discomfort in reporting such issues, as in Pakistani culture men are expected to be strong and any sign of weakness can lead to humiliation and mockery (Akram et al., 2015; Aqeel et al., 2019). While discussing confidence levels among caregivers, it was evident that male caregivers appeared to be more confident and assertive in their caregiving abilities. This again needs to be considered in the Pakistani context, where males are considered an authority figure and children fear their authority (Alvi et al., 2017; Aqeel et al., 2019). Although there was a range of experience, none of the caregivers had received any relevant prior professional training. This was in line with previous research reporting a lack of professional training and specialized knowledge among orphanage caregivers (Alvi et al., 2017; Bromfield et al., 2010; Deb, 2015).

The study elucidates caregivers' practical experiences, typical responses to challenging situations and how the constraints of time, finances and workload affect different areas of their professional and personal lives. It also informs us that there is a high need for validation, empowerment and capacity building that can be met through context specific structured training to promote caregivers' professional competency, help them feel empowered and help them excel in their role. Studies suggest that interventions or training programmes designed in the Global North; focusing on structural and behavioural changes is effective and acceptable in low‐income countries to enhance caregiving skills and capacity building (Gardner et al., 2019; Groark et al., 2005; Muhamedrahimov et al., 2004). Therefore, caregivers working in Pakistani orphanages could benefit from a programme that is designed around context specific needs and equip them in handling children in stressful situations, managing their own frustration and stress positively, along with enhancing the development of the children in their care.

As training that prompts behavioural changes in caregivers can encourage them to care for children as though they were their parents (Clément et al., 2016), resulting in more warm, sensitive and responsive caregiving that can enhance children's emotional and physical growth (Alem, 2020; Felitti et al., 2019). Prior studies have also recommended that there should be a clear job description, a well‐developed training strategy and a support system that promotes caregivers' wellbeing and encourages them to establish a sense of involvement and motivation (Forston et al., 2016; Çatay & Koloğlugil, 2017; Warner et al., 2017), as caregivers' capacity to provide emotional and psychological support is crucial for the child's positive developmental outcomes (Smaal et al., 2016; Stith et al., 2008).

Identifying factors affecting caregiver wellbeing, and deficits in skills training, is the first step in enhancing caregiving and reducing negative developmental outcomes in children who have been orphaned. This study sheds light on the main areas of support needed for these caregivers and shows a consumer‐driven demand for evidence‐based support and context specific training for the professional development and personal wellbeing of caregivers working in Pakistani orphanage settings.

5. LIMITATIONS

Only three orphanages agreed to participate in this research, and while these were diverse settings and organizational structures, it limits the generalizability of the findings. The interview format may have precluded disclosure of maltreatment of orphan children, although corporal punishment was discussed readily. Likewise, caregivers may not have felt comfortable discussing more structural issues related to the orphanages. It would be helpful in future to include orphanage administrators to get more detailed information about structural and practical constraints and inform the development of a professional training package fit for the context.

6. CONCLUSION

This study provided insight into practical issues that caregivers face daily in their personal and professional lives. It is evident that caregivers are motivated to provide the best care for children with diverse and complex needs, but they feel the pressure of workload and lack of training. There was a high expressed desire for context specific professional training that can support their caregiving of orphaned children, as well as professional and personal stress management. This kind of context specific training has the potential to enhance caregiver well‐being, confidence and competence, with resulting benefits to caregiver‐child relationships and long‐term child outcomes. Further research focusing on the administration and supporting staff in orphanages would be helpful in establishing a supportive environment. This could also inform structural and professional changes, such as hiring more caregivers to decrease workload, implementing job‐related training, and providing a medium for continuous professional support to all stakeholders within the orphanage for the positive caregiving of children under their care.

CONFLICT OF INTEREST

The Parenting and Family Support Centre is partly funded by royalties stemming from published resources of the Triple P–Positive Parenting Program, which is developed and owned by The University of Queensland (UQ). Royalties are also distributed to the Faculty of Health and Behavioral Sciences at UQ and contributory authors of published Triple P resources. Triple P International (TPI) Pty Ltd is a private company licensed by UQ, to publish and disseminate Triple P worldwide. The authors of this report have no share or ownership of TPI. Dr Morawska and Dr Turner receive royalties from TPI. TPI had no involvement in the study design, collection, analysis or interpretation of data, or writing of this report. Dr Morawska and Dr Turner are employees at UQ. Ms Khalid is a PhD student at UQ.

ETHICS STATEMENT

Ethical clearance was granted from the Human Research Ethics Committee of the University of Queensland (Approval number 2019001861).

AUTHOR CONTRIBUTION

Amina Khalid was responsible for conceptualization, methodology, writing original draft preparation, investigation, data curation and formal analysis.

Alina Morawska was responsible for supervision, conceptualization and reviewing and editing. Karen Turner was responsible for supervision and reviewing and editing.

Khalid, A. , Morawska, A. , & Turner, K. M. T. (2023). Pakistani orphanage caregivers' perspectives regarding their caregiving abilities, personal and orphan children's psychological wellbeing. Child: Care, Health and Development, 49(1), 145–155. 10.1111/cch.13027

DATA AVAILABILITY 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 privacy or ethical restrictions.