Standardization of a Participatory Questionnaire to Assess the (Fulfilment of) Needs of Children in Care (QANCC) In India

Abstract

India has approximately 23 million children without parental care, who need alternative forms of care (MOSPI, 2018). Udayan Care, an NGO, designed an innovative group care model for children and youth in need of care and protection, implementing the indigenously developed LIFE (Living in Family Environment) strategy in 17 Udayan Ghars. (Sunshine Homes). With child participation as a core pillar, Udayan Care developed a Questionnaire to Assess the Needs of Children in Care (QANCC) in 2011, which is to be filled up by children annually, as a longitudinal study. The tool is conceived to ascertain whether children in the Ghars perceived if their rights were being fulfilled and that their needs were being addressed. With “meaningful participation” of children stipulated by the United Nations Convention on the Rights of the Child (UNCRC), the objective was to develop an evidence-based tool to assess the views of children on the services meted out to them, from their standpoint, and inform actual care practices annually. The self-assessment tool consists of questions, assessing the four dimensions of basic/fundamental, emotional, educational, and interpersonal needs, on a four-point Likert rating scale. A convenient purposive sampling is done on children, aged 10 to 18 years, who receive care and protection at the Ghars, and have resided there for a minimum of 6 months. This paper has two objectives, where at one end, the deductions of the previous years’ data are made (2011–12 to 2016–17) with demarcating the differences with year 2018–19 data and at the second level, there is an update on the efforts made to establish the reliability and validity of the tool and create a standardized tool that can be implemented by other child care organizations in India. The paper illustrates how listening to direct voices of children and incorporating their inputs into actual care practice, can go a long way in improving the holistic wellness of children living in an alternative care setting. The results indicate that all needs of the majority of the children in Udayan Ghars.

Introduction

India is home to 23.6 million orphaned and abandoned children (MOSPI, 2018), and out of these, almost 470,000 children are in institutional care (MWCD, 2018). In order to meet with the challenges associated with children without parental care, governments world over have set up various alternative care options, including community-based, or family-based care (like foster care, kinship care, and sponsorship and other supportive schemes) and residential or institutional care (like group foster care homes, child care institutions). Various reasons associated with placing children in alternative care settings include orphan-hood, poverty, education, migration, disasters, trafficking, cultural factors and child sexual abuse. Even though institutional care should be the last resort for children, but in developing countries in Asia, institutional care is the dominant form of formal care provided by the State (Modi et al., 2016; SAIEVAC, 2011).

Amongst the 9598 registered child care institutions (CCIs) in India, 8744 homes are run and managed by NGOs and the ratio of number of homes to children, reinforces the stringent need for rationalization of child care institutions with a systematic planning and deeper analysis (MWCD, 2018). This study signifies the crucial need for assessment of care and quality of life provided to children in residential care. Titled, ‘Mapping and Review Exercise of Child Care Institutions’ it throws light on CCIs’ functioning in India, this study highlights major gaps prevailing in their functioning and indicated that most of the institutions lacked nurturing and stimulating environment for children (MWCD, 2018). There is a lack of data regarding educational, emotional and health needs of children in these institutions, and likewise rights-based approach is absent.

Lack of a Participatory Approach in CCIs

Several studies indicate that the voices of children were not heard, and they did not have the right to participate or freely express their views (Bajpai, 2019). Assessment of children’s quality of life cannot be achieved without taking into consideration children’s perspectives. There has always been a dearth of mechanisms which involved child participation and documentation of their concerns and most of the times, children’s voices are either ignored or addressed superficially (Singer, 2014; Whitty & Wisby, 2007).

United Nations Conventions on the Rights of Child (UNCRC, 1989) emphasized the importance of children’s participation in need assessment, as mentioned in Article 12. Participation of children is also mentioned in “The Juvenile Justice (Care and Protection of Children) Act”, 2015, which states that, “Every child shall have a right to be heard and to participate in all processes and decisions affecting his interest and the child’s views shall be taken into consideration with due regard to the age and maturity of the child”.

Other Consequences of Institutionalization

Children’s experiences in residential care show long-term-consequences, including difficulty in forming social relationships, issues related to personality functioning and other intellectual processes (Richter, 2004). Deficient institutional environments lead to developmental delays (Crockenberg et al., 2008), despite availability of the basic necessities like food supplies (Johnson et al., 2010). Lack of quality care and attachments provided in the child care institutions (CCIs) along with emotional and social neglect has been found to be associated with physical growth deficiencies and psychological dwarfism (McLaughlin et al., 2012; Smyke et al., 2014;). These children often lag behind other peers on certain parameters of physical growth, including weight, height, etc. (IJzendoorn et al., 2007). Children residing in institutions are generally deprived of opportunities to develop continuous and stable attachment relationships as they get inadequate and poor quality of contact with the caregivers in these institutions (Gunnar et al., 2000; Palacios et al., 2005; IJzendoorn et al., 2011; Zeanah et al., 2005). Disrupted education, compounded by multiple traumas, causes low motivation in children and youth; also, insufficient opportunities for education and vocational trainings lead to unstable and low paying jobs (Gatumu et al., 2010). Children without parental care are in a dire need of care and counselling, an understanding of their unique experiences by their carer group, as they are susceptible to long term mental and psychological problems like anxiety, depression, sadness, anger and tend to self-isolate and withdraw themselves from others (Nyamukapa et al., 2010; Pillay, 2018; Shiferaw et al., 2018).

Importance of Subjective Assessment to ensure Quality of Standards of Care for Children in Institutional Care

Quality of life of children can be determined by measuring a child’s subjective perception of their physical, social, and emotional life. This would give a clearer picture of the assessment of children in care homes (Mattejat et al., 1998; WHO, 1995), along with providing a parameter to evaluate mental health problems among children (Rogers et al., 2014; Sawyer et al., 2002).

A review of the ‘The Child Care Quality Rating System (QRS) Assessment’ and ‘The 2018 Santa Clara County Child Care Needs Assessment’, the most commonly used participatory scales for child care assessment in child care centers in the west, revealed that these scales are not designed for South Asian population and are thus not recommended for CCIs in India. Although, a comprehensive literature search did not reveal a tool, which had been validated and available, for use in a similar kind of CCI, with the definite cultural contexts in mind, there have been some subjective wellbeing assessments applied and promoted in other countries (Rees & Main, 2015) as well as research which has positive indicators of well-being (Ben-Arieh, 2000; Lippman et al., 2011; Modi et al., 2018). Child well-being domain constitutes physical health, development and safety; cognitive development and education; psychological and emotional development; and social development and behaviour. National Research Council (NRC) framework, The Multi-National Project for Monitoring and Measuring Children's Well-Being, Positive youth development (PYD) framework, College and workplace readiness framework etc. are certain current frameworks of positive indicators whose domains predominantly reflect positive child well-being.

The assurance, regular assessment, and improvement of quality of life of children in CCIs have to be ensured as it can help ascertain appropriate therapies and interventions to improve their well-being (Büttner et al., 2011; Tarren-Sweeney, 2008). There is no better way to achieve this than to listen to the child directly. Further, as stated by L.R. Knost; “Every day, in 100 small ways, our children ask, ‘Do you hear me? Do you see me? Do I matter?’ Their behavior often reflects our response. This led Udayan Care, an NGO in India, running child care institutions, to evolve a child’s participatory tool, to understand the needs of children in their homes.

Udayan Care- the Child and Youth Care Model

‘Udayan Care’, headquartered in New Delhi, India has developed a unique model of group homes, called ‘Udayan Ghars (Sunshine Homes)’ for children without parental care. Since the initiation of its first Udayan Ghar in 1996, Udayan Care has been using the indigenously developed strategy, namely, LIFE (Living in Family Environment) for their children’s homes. This strategy balances itself on five pillars of the model, those being, small numbers of children per home, a trained carer team, community orientation and involvement, education, vocational, and life skills training, and child participation. With single and sometimes double units of 12 same sex children, these 17 Udayan Ghars, as well as the two Aftercare facilities for its youth, are established in the mainstream middle-class communities, and children go to local schools to gain a sense of belongingness with their surroundings. The local standing helps these children re-integrate into the mainstream society. The carer team for each of the homes consists of a full-time, resident care staff (2–3 for every 12 children); social workers for every 24 children; part-time counselors, a psychologist and a child psychiatrist that are allied with the organization and facilitate in fostering a healthy relationship with the children (Modi et al., 2016). A unique feature of this model is, mentor parents, who are long-term, committed volunteers, who play a role of bringing parenting, social exposure and stability to the children. In order to build the teamwork spirit among the carer team, a series of workshops are conducted for different stakeholder groups including children themselves, so that they can work together for positively impacting well-being of children. Additionally, the legal, documentation and aftercare coordinators, along with the zonal coordinators (each assigned supervision of 4 homes), have an overall manager. Udayan Care believes in providing permanent and consistent form of care to children and thereby provides them an environment where they feel secure and stable. Individual Care Plans (ICPs) for each child are developed and reviewed periodically in consultation with the child, mentors, professional and care staff.

Need for a Participatory Tool to Assess Children’s Satisfaction Levels and to Improve the Working of Child Care Institutions

During periodic self -assessment of care strategies in Udayan Ghars, caregivers and children were found to have varied ideas about the control and care provided and that made it necessary to understand perceptual differences in care-giving from both the child’s and adult’s points of view (Modi et al., 2016). Validation and rating the quality of changes implemented required routine inputs from children receiving care via internal processes. Believing in participatory methodology, and a keen sense to hear children themselves, led to efforts to develop a tool. The desire to develop a tool which was fitting in its socio-cultural learnings to Indian settings led to the development of Questionnaire to Assess the (Fulfilment of) Needs of Children in Care (QANCC); as there was no standardized tool available for self-assessment in India with validation for use in a similar child care institutional setting.

This questionnaire, as a self-assessment survey, was designed, with the following objectives: (a) to assess the four dimensions of basic/fundamental needs, emotional needs, educational needs, and interpersonal needs of children in these child care institutions via longitudinal analysis, and to take corrective measures, and; (b) and thus, to develop and standardize an evidence-based indicator tool from the children’s point of view to assess whether their rights are being secured.

QANCC is administered to children in all the Udayan Ghars annually, and is aimed to assess the four main categories of needs of children, as enumerated above, aged 10–18 years (Modi et al., 2018). Provision and assessment of each need individually, and together, is necessary as a holistic approach towards improving care and quality of life individually as well as in the home; and has been found to be linked with their enhanced development, health, and school performance.

Instrument Development

The self-administered instrument was initially developed in 2011, after an extensive literature review and networking with various experts in the field, for inclusion of parameters which were deemed to impact child development. Major consultants included Dr. Kiran Modi, Managing Trustee and Founder of Udayan Care; child and adolescent psychiatrist, Dr Deepak Gupta; clinical psychologist, Ms. Hemanti Sikdar; and social workers, Ms. Garmia, Mr. Rahul, and Ms. Nidhi, who worked in the organization then. Content validity was achieved by obtaining inputs from professionals involved in the childcare profession regarding variety of concerns related to children in CCIs. The tool was developed with the desire to ascertain whether children residing in Udayan Ghars felt that their needs were catered to and their rights were secured. The statements coming out in the pilot study (as mentioned below) were judged by the experts based on appropriateness with respect to component and tool, relevance, and usability of the tool in Indian settings. Also, the questions were checked for grammatical errors, language and comprehension and were made clear, simple, and direct. The process of literature review was conducted thoroughly on the relevance and need for addressing the evaluation of the performance of the homes in executing holistic childcare. The components of child care which form the fundamental tenets were thus narrowed down to the four dimensions of needs for assessment, these being fundamental needs, educational needs, emotional needs, and interpersonal needs. In the year 2018–19, some minor modifications and some additional questions in the questionnaire were added, after giving a gap of one year in 2017–18.

Methodology

Pilot Testing of the Tool

The questionnaire was tested for a pilot in five randomly selected Udayan Ghars located across North India, in 2011 and to secure a better representation of the respondents, the tool was implemented across geographically spread Ghars, among 77 children. The questions were translated into Hindi and then back into English, using the help of language experts to retain the essence of the tool. For each statement, four options were provided, and children aged 10–18 years had to respond by ticking the box with assistance from the interviewers. The pilot study helped to gather the responses; analyze the time taken for administration, and the challenges encountered in surveying. Questions that were found to be repetitive, incomprehensible by children, and those unanswered were modified or deleted. To overcome the familiarity with the tool, the children who participated in the pilot survey were excluded from the final survey that year. The investigators followed the scoring procedure detailed by Likert (1932) for the positive and negative polarity of the statements.

Participants

Data was collected annually through the survey tool, administered to all the children, aged between 10 to 18 years, who had lived at an Udayan Ghar, for a minimum period of six months, through convenient purposive sampling. The age group of 10–18 is chosen with an intent to avoid biases, arising due to the interviewer’s inputs and suggestive over-explanation of tools to younger children because of the lack of language development.

Even though the survey was designed to be self-administered, questions were read to the younger children (till 13 years of age) and their answers were recorded individually. To ensure adequate comprehension by them, children were asked to repeat the questions in their native language which was initially read to them in English. Older children (14–18 years) filled the questionnaire themselves. Chances of social desirability bias arising due to children’s dependency on known individuals were reduced by involving interns to conduct the survey, who were previously unknown to the children, and were trained to administer the tools by following a standard protocol. Ethical considerations like voluntary participation and obtaining informed consent were considered for the administration of the questionnaire under strict ethical standards for research established by Udayan Care.

Longitudinal data from each of the homes, starting from 2011 till 2019, was collected on a yearly basis around October or November by trained interns. Data from 2011–2012 implies, that the data was collected from April 1, 2011 to March 31, 2012 in keeping with the school year and financial year in India. The year 2011 served as a pilot year while a gap year was implemented in 2017–2018 to minimize the carry-over effects. The gap year was used to review the tools and incorporate changes necessitated by contextual alterations over the years, to aid the standardization process. Some minor modifications and some additional questions in the questionnaire were added in 2018–19, after giving a gap of one year.

Organization of Instrument

Scoring

The self-assessment questionnaire comprised of 50 questions and 80 statements in the year 2018–19, whereas the previous tool had 35 questions and 64 statements in total. The four main parameters of children’s fundamental needs, educational needs, emotional needs, and interpersonal needs, along with the demographic profile of the respondents, remained unchanged. Each of the needs highlights the cores that are needed for the overall physical and mental development of children, leading to their overall development. Certain questions were reframed, their sequential order changed, and irrelevant sections removed with expert suggestions. The revised tool added open-ended, sub-questions which were framed in a manner to describe activities undertaken, feelings experienced, self-realization, and participation of children in group activities and their interaction with staff.

A total of ten items were framed under basic needs with an objective of assessing the provisions of essential basic comfort of clean and hygienic home setting, conducive for sleep, adequate medical support, good quality and enough food, availability of resources such as study materials, recreational and extra-curricular facilities to the children in Udayan Ghars.

Assessment of emotional needs was determined using a total of 28 items, where a few additional questions were included in 2018–2019 after the gap year. The questions attempted to assess whether adequate guidance and mentorship, emotional support, and counselling were being received by children from the CCI staff and mentors. It also looked at the aspects of guidance on matters related to sexuality, sexual health, and gender identity to children; experiences of abuse and threat within homes and outside; the level of trust to share emotions with the care staff and receiving prompt and careful responses from caregivers. Another vital aspect addressed via questions was to determine whether there had been any support received by the children about overcoming dependence on harmful substances and behaviors (alcohol, tobacco, drugs, self-harm, vandalism, etc.).

There are five separate questions (no additional questions added) under educational needs assessment which touch upon quality and adequacy in guidance and support for studies and/or career, opportunities to explore interests at school, and support to identify and develop their unique skills and talents. Perspectives of children, on whether they managed self-study or got assistance; their level of awareness about their shortcomings and weakness in an educational atmosphere including self-introspection and comprehension, were very useful to develop recommendations.

The last category of seven questions (no additional questions added) attempted to map the interpersonal needs of children, including the need for social acceptance, prestige; a sense of community belonging; and their access to certain people, events, or resources. Children’s participation in household activities; extension of support to fellow children in the CCI; access to help and care by care staff; interpersonal relations with other children; sharing of emotions with them and supporting them in time of need were evaluated. Sense of belongingness and acceptance was assessed by measuring the extent to which children feel comfortable in accepting and expressing themselves as being children in the alternative care setting.

For each question, a four-point Likert scale was asked to be rated according to the respondent children’s perception of needs being met at the CCIs. The Likert scale was rated as ‘Never’, ‘Sometimes’, ‘Most of the times’, and ‘Always’, with values ranging from 1 to 4 correspondingly. The tool also consisted of open-ended questions where the children could share their views and anecdotes about their perceptions and attitude towards their ratings as supportive evidence to their responses. Care was taken to avoid double negatives and the rating scale was arranged in a ranking order, i.e., 1 equates to never and 4 equates to always. The statements regarding the broad groups of needs were shuffled in the questionnaire to avoid biased responses. Randomization was essential for the arrangement of statements in a scale as it would eliminate patterned responses which might result if all the statements belonging to a particular component concentrated at one part of the scale.

The Likert scale statements followed a unidirectional pattern so that there was no confusion among the children. Furthermore, to build on the ratings which were given poor scores under each question, additional questions, based on the rank order of suggestions for improvement in the delivery of needs at CCIs, were also placed in the questionnaire. This was done as a method of obtaining feedback from the respondents for ensuring future improvement in care planning and management.

Overview of Factor Analysis and Validation Analysis

The next stage of the development of the questionnaire to assess the needs of children in care consisted of ratings of face validity by experts followed by testing of construct validity, component analysis and reliability. Face validity of the scale was ensured before construction of QANCC scale. To ensure the content of commitment being measured using the professional QANCC scale, content validity was measured. This was achieved through suggestions and feedback from experts for ensuring the content coverage concerning the components of the scale and incorporating their inputs for the final construction of the tool. The content validity of the final questionnaire was determined to keep in consideration the clarity, relevancy, simplicity, and consistency of each question within the question set. They evaluated the instrument for crucial deletions or inappropriate choices of items.

Factor Analysis and Variance

For principal component analysis, the Kaiser–Meyer–Olkin (KMO) Measure of Sampling Adequacy for this tool is 0.503. As this number is not remarkably high, the data obtained (Appendix 1) was inadequate and unsuitable for factor analysis. This could be due to sampling size issues. Similarly, Bartlett’s test of sphericity conducted for homogeneity of variance was found to be significant (p < 0.01), indicating sufficient correlation between the variables. It was found that percentage of variance/variation explained by individual questions is not remarkably high for all. Therefore, all the statements do not have good extraction value; they exhibited moderate or high homogeneity in substantiating item validity with respect to the QANCC scale, and further analysis was done using Varimax Rotation. Listed in the Appendix 2 are the six Likert statements/questions which have less than 30% variation.

Factor analysis was done for data reduction and grouping the related variables in conceptually similar and statistically related groups. For the QANCC tool, the Varimax rotation method under principal component analysis was used, where we extracted factors based on Eigenvalue greater than 1. KMO measure of sampling adequacy and Bartlett's test of sphericity were further used and cut off point for loading on each factor was found to be 0.4. It can be concluded that 16 factors (components) in the initial solution have Eigen Value over one. They account for 70% of the observed variation among children of care homes in terms of their satisfaction of the needs met in the homes.

Variance and Standardization of Tool

Norms are the standard of reference required to measure the magnitude of deviation of an individual’s score from the general population average. For the total score, a summation of all statements of the QANCC Likert’s scale has been performed. In the year 2018–19, among the 96 children respondents, the minimum score was 126 and maximum was 184 out of the total obtainable/possible score of 200 (50 questions * 4 marks (if all questions are marked as 4 or always met). The average score was found to be 162.

The variance of 80 questions of the QANCC scale was individually calculated and found that 12 questions with question numbers Q. 22C,D,E,F; Q.26; Q.4A,C,E,F,G; Q.5 A; and Q.28 had a high variance and thus can be removed or modified. The variance was also calculated for need wise categories and was found to be high for mean educational needs (0.226) followed by interpersonal needs (0.151).

Variance Across Four Major Needs

T-tests were performed to demonstrate whether the hypothesized relationships between the known-groups and QANCC domains were statistically significant. T-tests were performed between two groups of respondents where, the first group consisted of respondents with a total score (summation of all 80 Likert’s scale statements) of more than upper Quartile; and the second group consisted of respondents with a total score (summation of all 80 Likert’s scale statements) of less than lower Quartile. So, the T-tests between these two groups in terms of the level of significance by 50 questions show that question numbers Q.7, Q10, Q1C, Q2, Q5, Q4G, Q5_A, Q2_A and Q 28 do not have a significant difference between the groups and thus, can be removed or modified in the QANCC questionnaire. These nine questions do not capture the difference among the respondents significantly when the respondents are divided into 2 groups (those who lie at the higher end of scores and those who lie at the lowest end of the scores).

Reliabity Testing

For measuring the consistency of the QANCC tool, the Cronbach’s Alpha Reliability was computed, which is commonly used in cases of multiple Likert questions in a questionnaire. This test was used to comprehend whether all the questions in this questionnaire reliably measure the same latent variable. A reliability analysis was carried out for the QANCC scale; in totality and among the four disaggregated components of needs. The value of the Cronbach’s Alpha Coefficient for the component of basic needs is 0.576 (when N = 10); for the component of emotional needs is 0.681 (when N = 28); for the component of educational needs is 0.506 (when N = 5), and for the component of interpersonal needs is 0.423 (when N = 7). The value of the Cronbach’s Alpha Coefficient for the overall needs for the QANCC is 0.777 (when N = 70, questions which make up overall needs assessment).

The table (in Appendix 4) shows that if we remove the following questions mentioned in Appendix 5 from the QANCC scale component; then the overall reliability would improve to 0.778, 0.778, 0.778, 0.780, 0.778, 0.780, 0.787, 0.784 and 0.783 respectively. The correlation for these questions was low at 0.42, 0.74, 0.002, 0.76, 0.102, 0.065, -0.47, 0.14 and 0.009 respectively.

To interpret the output, one can follow the rule of George and Mallery (2003): > 0.9 (Excellent), > 0.8 (Good), > 0.7 (Acceptable), > 0.6 (Questionable), > 0.5(Poor), and < 0.5 (Unacceptable). Thus, as its coefficient value is 0.777, the QANCC scale ranks in between acceptable and good. These nine questions under each needs’ sub-group were either ambiguous, repetitive, or incomprehensible to the respondents. As the reliability of the tool is found to be more than 70%, it falls under the range of acceptable and good. After finalizing, modifying and testing this tool longitudinally for several years in child care setting, and thereby evaluating its reliability and validity, this tool is now ready to be widely used and can be applied to even bigger sample sizes and in different alternative child care settings in Indian context.

Results

Overview of Data Analysis

Longitudinal Trend of Overall Needs Fulfillment

The longitudinal data recorded from 2011- 2019 with the gap year of 2017–18 was analysed. The age group wise disaggregation of the children across the years depicts that primarily most children were in between 13 to 15 years, with more than 30 children aged 12 years in 2013–14, 25 children each aged 14 years, 15 years and 16 years in 2014–15, 2015–16 and 2016–17 respectively were residing in the Udayan Ghars. The overall rating scale from 2011–12 to 2014–15 shows that percentage of responses under the ‘always met’ satisfaction category saw a steep rise of 19 percentage points (48% in 2011–12 to 67% in 2012–13) but it declined back to 48% in 2014–15. While the percentage response under the ‘never met’ category rose from 7 to 13% during the same time span, but again declined to 8% in 2015–16. Under the ‘most of the times’ response category there was gradual rise from 14% in 2012–13 to 32% in 2015–16. The year 2011–12 which was the initiation year for the data collection at the Ghars, saw many CCIs not coming under data collection. Out of the thirteen homes then, the data was collected only at eight homes, since Home 13- was established in year 2013 and since then two more homes were set up and were included under the QANCC data collection and assessment program thereafter; making a total of fifteen homes for data collection in 2018–2019, coming down to a total of 96 children respondents. Figure 1, describes the trend of fulfillment of overall needs.

Fig. 1.

Trends in the fulfilment of Overall Needs of Children in Udayan Ghars (2011–19)

Response Rate Among Various Udayan Ghars

For the purpose of easier evaluation, a chronological method of care home performances was made and taken into account, that higher percentage values under the ‘always met’ category and lower percentages under the ‘never met’ category indicated that the satisfaction of overall needs is higher among the children. The percentage responses under ‘always met’ and ‘never met’ category were examined, taking 2012–12 as the base year and 2016–17 as the end year before the gap year, and some key points are highlighted. Among the thirteen homes covered, all homes except two, had registered a decline in responses under ‘never met’ category. Rest of the homes were identified, and several measures were undertaken to improve needs fulfilment and consequently the response rate to ‘always met’ category of needs fulfillment. If we take combined responses of categories, ‘met most of the times’ and ‘always met’ together; on an average, almost all homes report the needs to be met with more than 80% responses. Considering the base year (2012–13), except two homes, all other homes achieved more than 70% under the combined responses. Though 2013–14 showed more or less similar trend, but in 2014–15 around 8 homes had responses less than 70% under the ‘always’ and ‘most of the times’ category combined as mentioned in Fig. 1.

Need Assessment of Four Broad Categories

When disaggregating the data into types of needs, another pattern was observed. The longitudinal analysis from 2012–17 indicated that on an average, 80% of the children at Udayan Ghars felt that their overall needs were being fulfilled. The average mean score for all ages in 2018–19 was 3.25 varying from 3.18 for girls and 3.32 for boys. In the year 2018–19, the mean score for the overall needs was 3.25 for the 10 years’ old children, while it was 3.24 for children aged 18 years (Fig. 2).

Fig. 2.

Mean scores of Overall Needs by Gender among Children in Udayan Ghars (2012–19)

The evident difference in the positive response measures of four homes recorded longitudinally in these years improved the following years’ responses, due to focused measures taken by carer team. Among the thirteen homes, all homes except two, namely Home 2- and Home 3 have registered a decline in responses under ‘always met’ category. Both these homes have seen a marginal improvement under the ‘always met’ category within the four-year time period. Home 4and Home 5- have seen the greatest decline in responses; from registering more than 80% responses under the ‘always met’, they have come down to 46% and 61% respectively in between 2012–17. There was a universal drop in the scores of basic needs, educational needs and interpersonal needs across Homes’ but the drop was relatively higher in the context of emotional needs where the mean score dropped from 3.3 in 2012–2013 to 2.8 in 2014–2015.

Source: Generated from primary data collected using QANCC (2012–19). Incidentally, all four broad needs show decline in their percentage distribution from 2013–14 to 2015–16 under the ‘always’ met category. In 2013–14, basic, interpersonal, educational, and emotional needs were 0%, 5%, 10% and 19% respectively under the ‘always met’ response category. The pattern was similar, but the deprivation percentage points were much higher except for basic needs. Contrastingly, in 2015–16, the proportion responses under ‘never met’ category were 1%, 4%, 5% and 12% for basic, interpersonal, educational and emotional needs correspondingly, thus clearly indicating the order in which the focus must be drawn to improve the provisions for the needs of the children. The follow up of the mean scores after the measures were implemented to improve emotional needs showed that the overall average scores went up in 2016–17. Certain measures were taken to improve the results and cater to needs of children. These included inclusion of a psychologist for at least 6 h a week in all homes from 2014 onwards who worked with children on an individual level and with the carer team; conducting workshops and life skills training sessions with children. Thus, data on the overall needs from the QANCC were used to tailor groups with the carer team which led to formation of specific committees to address Education, Health, Aftercare, and for Alumni on a monthly basis to discuss need gaps and targets for intervention. The data also helped in revising care plans for each child in all the care homes.

Analysis after the Gap Year

In 2018–19, data from 96 children, aged 10 to 18 years, residing in fifteen Udayan Ghars, was collected. Around 14.6% of children were less than 12 years of age, 66.7% in the age group 12 to 16 years and remaining 18.8% in age bracket of 17 to 18 years of age. Gender wise distribution shows that almost 73% of children were girls and 27% were boys. The mean score for all ages was 3.23 while the mean score was 3.22, 3.17, 3.26 and 3.25 for the age groups of less than 12 years, 12 to 14 years, 15 to 16 years and 17 to 18 years respectively. Analysis of the data indicates that, overall, 53% of the children felt that their comprehensive needs were being met but there was a gap of almost 20% of the responses which were either never met or met occasionally. In 2018–19 data, overall ratings for the responses reflect that on an average a little more than 50% of the children in each home have been satisfied with their four broad core needs and have stated that their needs are met always.

Longitudinal Analysis of Needs

The trend of all four major needs over the years 2012–19 is depicted in Fig. 3. Amongst all the needs, basic/fundamental needs are fulfilled the most followed by educational and interpersonal needs. Emotional needs have seen a great variation over these years which has seen the maximum decline during 2014–15.

Fig. 3.

Mean scores of four major needs among children in Udayan Ghars (2012–19)

Basic Needs

Some more variations were noticed in 2015–16 across the homes. Among the basic needs, Home 1 had only 47% responses under the ‘always met’ category, while Home 6 had the highest responses at 90%. The basic and fundamental needs under the ‘never met’ category has the lowest variation and all percentage figures are under 5%. In 2018–19, the results were further stratified as follows and under basic needs, more than 3/4^th of the responses was marked as ‘always’ and only 20% of the responses under basic needs were categorized as never met. In 2018–19, invariably almost all the homes derive a good picture from the children’s responses about their basic or fundamental needs being always fulfilled.

Children have stated the following statements to support their answers. ‘Didi’ (caregiver, who is called ‘sister’) cleans the room everyday’, ‘cleaning lady comes, caregiver cleans and he helps out too’, ‘home is never dirty’, ‘It is always cleaned by any one or other’. They also talk about how the home environment is always conducive for living and state that ‘air coolers are present, comfortable beds are there’, and ‘because the care staff listen to us’, and thus their needs are met. Provision of food is never an issue as ‘I get food whenever I need it’, ‘I never sleep hungry’, and ‘tummy full food’ is available. Children have also stated that ‘we get opportunity to visit park, have equipment's to play, books and everything else to pass our time’, ‘When I am sick, Bhaiya (caregiver, who is called ‘brother’) takes me to the hospital’, ‘If I don’t do well in any subject, they motivate me to study’. Thus, these statements throw a light on the assured availability of the basic and fundamental care at the homes.

Emotional Needs

Every year as per the data, emotional needs of the children were not being satisfied. Only, 51%, 42% and 39% of the responses for emotional needs for the years 2013–14, 2014–15 and 2015–16 came under the ‘always met’ category unlike 83%, 71% and 67% for basic needs correspondingly. Variation was relatively more visible for emotional needs as the lowest response is 4% and the highest being 19% under the ‘never met’ category for the year 2015–16. There was a greatest drop in the scores of emotional needs across homes where the mean score dropped from 3.3 in 2012–2013 to 2.8 in 2014–2015. Follow up of the mean scores after certain measures were implemented in homes to improve emotional needs showed that the overall average scores went up from 2.8 to 3.1 in 2016–17. In 2018–19, relatively a much lesser proportion (45%) of the care-based children stated that their emotional needs were always fulfilled. It is important to note that almost 28% of children responded that their emotional and psychological needs remain ‘never’ fulfilled or only ‘sometimes’ fulfilled. The data also shows that questions on aspects of sexual health, sexual identity, assistance in overcoming substance addiction and abuse were responded under ‘never’ or ‘sometimes’ categories, implying a vast scope of work is required to be done in these areas with the care recipients.

Most of the questions probing whether the children share their problems, difficulties and feelings with their caregiver/mentor/teacher/supervisor/fellow children or others fell under the category of ‘never’. Overall emotional needs satisfaction under ‘always’ fulfilled category for the year 2018–19 is severely lagging. Children gave mixed responses stating, about their emotional needs that, ‘there are some fights which takes place sometimes’, ‘I do not feel like I belong here and want to leave and start my own life’, ‘I'm not heard when I speak up or they shut me off’, ‘children listen to what I say but sometimes, the caregiver and the coordinator do not’, ‘I sometimes feel unloved when some argument occurs’. On the other hand, a large proportion of the children contrastingly felt that their emotional needs are being fulfilled and statements like, ‘they treat me like their own family’, ‘they respect me and here everyone has a say’, ‘I feel very close to supervisor and coordinator’, ‘even if we get angry, didi (caregiver sister) makes sure we eat and she does not let us sleep without eating’ stand as testimonies. Some new questions regarding sexual health, identity, abuse and violence were added and it again elicited mixed responses such as, ‘we have regular workshops on sexuality and sexual health’, ‘as there are sessions taken by counsellors, social workers’, ‘it helped us gain understanding about the concerned topics’, ‘we are given sessions on several topics including menstruation and safe and unsafe touch’. Few other responses included ‘I feel like talking to someone at least once a week separately (mentor, social worker, counselor)’, ‘I do not feel attached to mentor mother’.

Educational Needs and Interpersonal Needs

The interpersonal needs ranked second after emotional needs with lesser responses under the ‘always met’ category. There was a universal drop in the scores of interpersonal needs and educational needs across homes from 2012–13 to 2014–15. The mean scores for educational needs ranged from 3.4 in 2012–13 to 3.2 in 2013- 2016 and later rose to 3.3 in 2017 whereas on the other hand, mean scores for interpersonal needs ranged from 3.5 in 2012–13 to 3.3, 3.1, 3.1 and again 3.3 from 2013 to 2–17. In 2018–19, a little more than half of the responses came under ‘always’ for the educational and interpersonal needs. Around 5% and 4% of the responses for the same were categorized as ‘never met’ by the children and focus must be devoted to address this unmet need among the children. Most of the ‘never met’ responses were reported from whether the children were assisted in understanding/realizing their weaknesses and shortcomings and unfortunately most children felt that they weren’t comfortable in telling others that they belong to Udayan Ghars or a CCI. For the year 2018–19, almost all homes except a few performed satisfactorily well in fulfilling the educational needs of the children. Although interpersonal needs overall fare better relative to the emotional needs (52% against 45.1%) and that the homes also report higher percentages under the ‘always met’ category, there still exists a discrepancy among the homes in this regard.

Children receive guidance for pursuing their career choices, hobbies and also their extra-curricular interests are supported enough. This is notably visible from the children’s responses such as; ‘we are given regular career counselling workshops’, ‘we have an alumni friend pursuing engineering with whom we interact and he listens to our ideas and appreciates us’. Another child stated that they ‘get constant encouragement from everyone to pursue interest areas’, ‘we have all equipment's for drawing and sports.’ For the year 2018–19, which follows the gap year, interpersonal needs fulfilment gap remains. Questions pertaining to whether the children can discuss their feelings and problems freely or not and whether they have friends or not are essential to assesses the social respect, interaction that the children have at their homes and their surroundings Thus responses such as ‘I don't share my feelings with anyone and I try to keep myself busy’, ‘I can't trust everyone’, ‘I always help others and I take a lot of responsibilities’, ‘I try to help as much as possible’, ‘others make fun of me’, ‘my friend helps in making the bed, homework, depending upon mood’, ‘teachers knows that I stay here in this home but she asks about my parents in front of the whole class and it is a bit humiliating for me’, etc. are crucial to understand the actual emotional needs gap. A mixed response is what is received from children on their interpersonal relationships, majorly in two homes, but there is scope of much needed improvement in tackling the development of interpersonal skills, communication, and mentoring among the children.

Discussion

This study presents findings from the longitudinal study conducted to develop and validate the self-administered questionnaire, the QANCC, a tool measuring quality of life of children in CCIs which further reflects children’s subjective perception of their own physical, social, and emotional life circumstances. The responses for 2018–2019 must be evaluated separately owing to the following factors. First, there were fifteen homes as against thirteen homes previously and second, for 2018–19, the questionnaire was modified to include additional questions pertaining to sexual identity, sexual health, substance abuse and violence along with minor changes in the sequencing in the questions. The importance of healthy sexual development and comprehension about sexual identity among adolescents impacts overall physical and mental wellbeing and is recognized by WHO and various studies (Cook & Fathalla, 1996; Satcher, 2001; UN, 1994). Further, experience of violence and vulnerability to abuse by children and young people living in CCIsis widely recognized (Brodie & Pearce, 2017) and thus justifies the inclusion in the questionnaire for undertaking suitable safeguarding measures. Longitudinal results from 2012–2017 indicated that, on an average, more than 80% of children felt that their needs were being met. The data analysis visibly reflects that, the fundamental or basic needs were met in all the homes. Moreover, even though some children did respond that their educational needs were not being met always, they reported to receive apt guidance for pursuing their career choice, and hobbies and extra-curricular interests were duly supported. Several studies (Goemans et al., 2016; Oswald et al., 2010) highlight that, children in child care institutions are more vulnerable to develop social-emotional problems and emotional support and supervision is crucial in the development of children (Jacobsen et al., 2020). Emotional needs satisfaction in almost all of the Udayan Ghars varied disproportionately and remained the most unfulfilled need. As most of the children were aware of their weaknesses, it makes them relatively equipped, as self-awareness is a crucial step in making suitable improvements in the children’s lives so that their true potential is harnessed. Interpersonal needs that assess social respect, and interaction and facilitates in developing the sense of belongingness among the children were found to be mostly unmet and needs focused intervention along with emotional needs from the child care institutions authorities.

Most children, while responding, often limit their answers to that specific point of time and their ideas of vulnerability are often dogged in influencing their say. This vulnerability could be backed up by many factors including emotional and physical limits of their ability to enunciate their own concerns and interests, power differentials with the care staff and the interviewer, and their own vulnerable backgrounds. The quality of life and the fulfilment of needs in these CCI settings in the 2018–19 year are also compared to their previous years’ circumstances and experiences in these CCIs. Factors such as the duration of stay of children at CCIs often inform their responses.

Limitations

The wide variation in the responses in a single home as highlighted in few years’ data, indicates that while some children are highly satisfied with their needs being met; others are not, and there is a heightened need to focus attention on the reasons behind this discrepancy. Reasons can range from faulty collection of the data, to non-uniformity of surveys undertaken, with a probability that few children may not have comprehended the questions and thus, given unreliable responses. There is also a possibility that there was a lack of objectivity among the children while responding or there was disparity in the care provided in the homes.

Recommendations for Future Research

Need assessment is vital to ensure a good quality of life for children in institutional care as the data across the years would help identifying gaps and guide where to target interventions. Need assessment should also be a relevant rationale for providing psychotherapeutic treatment to children. The process of the needs assessment can build relationships between stakeholders and children and thereby build support for necessary actions (Sleezer et al., 2014). Need assessment can upkeep evaluation by developing an understanding of children’s needs, and hence can then measure whether these needs were met or not (Rossi et al., 2004). More knowledge about the effects of such treatments on children and youth is required where need assessment helps in identifying gaps and providing interventions and regular evaluation. The results derived from the tool over the years have been substantial in exploring children's needs and its fulfilment from children’s perspectives and paves the way for delving into deeper investigations.

Appraisals of Changes Made and A Way Forward

Upon identifying areas of unfulfilled needs, interim measures were taken to improve the quality of care, such as enhanced psychosocial support, workshops and life skills training, establishing specialized committees to address children's education, health and aftercare needs, and revision of care plans for children. The variation in the positive response rate along these several years indicated the order in which the focus must be drawn to improve the provisions for the needs of the children. The difference in figures within years’ draws a distinct enhancement of the fulfillment of needs among children because of measures taken by Udayan Care. Similarly, investigation of the pattern of needs fulfilment helped in identifying the gaps in a specific order and priority. More workshops are streamlined in future to boost child participation and ensure their voices are being carefully attended to.

To rectify the various areas of concerns, Udayan Care catered for regular counselling sessions and therapeutic treatments for children requiring additional support. In addition to the social workers, a child psychiatrist, more number of psychologists and counsellors were hired before the gap year for every ‘home’ to help children get support on a one-to-one basis. Life skills training and workshops for children were conducted regularly apart from guidance workshops for the carer team were conducted regularly regarding how to tackle the unmet needs of children. Development and continuous examination of individual care plans for each child was followed by the formation of specific measures being undertaken. Life skills module teachings were provided periodically to the children on the basis of the meetings held between psychologists and the carer team. These strategies helped and the questionnaire has helped initiate a self-motivated child-care practice whose results can be used to execute an informed care and also bring about a child-led and a more collaborative participation among the stakeholders.

Conclusion

Data analysis clearly states that all needs of the majority of the children in Udayan Ghars are met and the results are coherent with the studies from various situational and cultural contexts determining that children in CCIs encounter good quality of life. These findings should not be used to determine that CCIs are better settings for children without parental care than family or community-based settings but rather these two settings may not be different when it comes to children’s psychological well-being. It is the availability of various components of quality of care received in the care settings that makes the qualitative difference and create the overall experience in children of care received. Gander et al., (2019) in their study, determined that the fulfilment of needs and improved quality of life in CCIs are associated with a decrease in mental health problems. Thus, CCIs must expand the provisions of evidence-based needs assessment and the subsequent corrective treatment for improving quality of life of children. The analysis holds contradictory to few studies (Nelson et al., 2007; Zeanah & Gleason, 2015) which state that residential care settings including CCIs are associated with poor child outcomes like poor psychological well-being of children. But our study shows that listening to children, helping them reflect, and encouraging development of their agency, definitely brings out better outcomes.

This QANCC tool based survey, has provided opportunities to children in CCIs to offer their opinion and raise their voices on matters relating to their lives and their needs. This has made a substantial difference and has impacted the decisions of the management in running Udayan Ghars, while ensuring well-being at an individual level. After implementing this tool since last eight years, gathering and analyzing the responses; modifying and deleting the questions which were found to be repetitive and incomprehensible by children; this tool has been validated and standardized following research protocols and is ready to be adopted. The model had been implemented with a desire to impact lives of children without parental care in a structured and evidence-based manner. It is further hoped is that it will be utilized sincerely by other institutions and care providers across CCIs to actively listen to children and incorporate their voices and feedback into real-time care planning and thus lead to better child care practices (Tables 1, 2 and 3).

Table 1.

Descriptive Statistics for Likert Scale

Likert Scale	N	Minimum	Maximum	Mean	Std. Deviation	Variance
Total-score	96	126	184	161.66	12.081	145.954

Source: Generated from primary data collected using QANCC (2018–19)

Table 2.

Independent Sample T-Test

	Levine’s Test for Equality of Variances		T-Test for Equality of Means
Questions	F	Sig	T	Df	Sig. (2-tailed)
In case of medical illness & emergency, I get adequate medical support (Q7)	0.871	0.355	0.463	48	0.646
			0.463	46.517	0.646
I like the food at home (Q10)	1.104	0.299	1.21	48	0.232
			1.21	47.955	0.232
My home is clean and hygienic (Q1C)	2.909	0.095	0.623	48	0.536
			0.623	44.983	0.536
I take responsibility in keeping my home clean (Q2)	0.927	0.34	0.688	48	0.495
			0.688	47.287	0.495
I feel safe and secure at home (Q5)	0.689	0.411	0.385	48	0.702
			0.385	40.448	0.702
Everyone in the home helps me when I ask for it (Q4G)	0.457	0.502	0.471	48	0.64
			0.471	47.715	0.64
I feel safe and secure at home What makes you say that (Q5_A)	3.999	0.051	0.849	48	0.4
			0.849	44.985	0.4
I take responsibility in keeping my home clean (Q2_A)	0.205	0.653	1.136	48	0.262
			1.136	47.643	0.262
I feel comfortable in telling others that I am from a child care home (Udayan Ghar) (Q28)	2.06	0.158	0.59	48	0.558
			0.59	44.781	0.558

Source: Generated from primary data collected using QANCC (2018–19)

Table 3.

Combined Responses under Most of the Time and Always Met Categories Across Udayan Ghars, (2012–19)

Responses with Most of the times + Always	2012–13	2013–14	2014–15	2015–16	2016–17	2018–19
Home 1- Sant Nagar	86%	64%	69%	59%	47%	80.5
Home 2- Mayur Vihar	61%	62%	58%	75%	79%	67.2
Home 3- Mehrauli	77%	82%	70%	81%	84%	78.8
Home 4- Greater Noida	91%	70%	71%	73%	78%	80.3
Home 5- Gurgaon	90%	73%	77%	82%	82%	73.4
Home 6- Noida Boys	88%	71%	83%	93%	76	81.6
Home 7- Noida Girls	81%	72%	65%	78%	84%	84.0
Home 8- Mayur Vihar	64%	73%	56%	85%	83%	87.2
Home 9- Kurukshetra	91%	89%	91%	90%	97%	79.3
Home 10- Jaipur	90%	79%	72%	59%	73%	85.8
Home 11- Ghaziabad	94%	93%	74%	74%	80%	77.3
Home 12- Mehrauli	56%	69%	62%	71%	77%	85.0
Home 13- Sant Nagar	-	83%	63%	66%	68%	74.8
Overall average	81%	74%	70%	82%	77%	78.0

Source: Generated from primary data collected using QANCC (2012–13)9

Appendix 1

KMO and Bartlett's Test

Kaiser–Meyer–Olkin Measure of Sampling Adequacy		0.503
Bartlett's Test of Sphericity	Approx. Chi-Square	1988.757
	Df	1225
	Sig	0.000

Source: Generated from primary data collected using QANCC (2018–19)

Appendix 2

Principal Component Analysis of the QANCC Scale

Question No./Questions Statements	Initial	Extraction
Q.6 (My home environment is conducive enough for a sound sleep)	1	0.287
Q. 5 (I feel safe and secure at home)	1	0.132
Q.22F (I share my concerns/feelings/problems with)	1	0.22
Q.24 (I feel confident in the outside world)	1	0.267
Q.5A (I feel safe and secure at home)	1	0.138
Q.2A (I take responsibility in keeping my home clean)	1	0.236
Extraction Method: Principal Component Analysis

Source: Generated from primary data collected using QANCC (2018–19)

Appendix 3

Descriptive Statistics Across Four Needs

Needs Group	N	Mean	Std. Deviation	Variance
Basic needs	96	3.7052	0.24979	0.062
Educational needs	96	3.3083	0.47499	0.226
Interpersonal needs	96	3.3051	0.38813	0.151
Emotional needs	96	3.0331	0.29724	0.088

Source: Generated from primary data collected using QANCC (2018–19)

Appendix 4

Cronbach’s Alpha for Reliability Testing of the QANCC

Question No	Scale Mean if Item Deleted	Scale Variance if Item Deleted	Corrected Item-Total Correlation	Cronbach's Alpha if Item Deleted
Q1C	158.104	144.915	0.042	0.778
Q2	158.031	144.473	0.074	0.778
Q5	157.75	145.811	0.002	0.778
Q22D	158.844	143.017	0.076	0.780
Q23	158.229	142.936	0.102	0.778
Q4E	158.781	143.331	0.065	0.780
Q4G	159.833	145.93	-0.047	0.787
Q5A	158.333	144.098	0.014	0.784
Q28	158.302	144.634	0.009	0.783

Source: Generated from primary data collected using QANCC (2018–19)

Appendix 5

Question Statements for Appendix 4

Question No	Questions in Statements
Q1C	I have enough resources to do things I want and live comfortably at home, like, play things and recreational materials?
Q2	I am supported for any additional needs I have in my studies, health and development?
Q5	I feel safe and secure at home?
Q22D	I share my concerns/feelings/problem with the concerned social worker/ mental health professional?
Q23	I feel safe in my neighborhood?
Q4E	If I feel threatened or experience abuse, I reach out for help to concerned Mental Health Professionals?
Q4G	If I feel threatened or experience abuse, I reach out for help to any other?
Q5A	I am supported to overcome any dependence I have to harmful substances and behaviors [alcohol, tobacco, drugs, self-harm, vandalism etc.]?
Q28	I feel comfortable telling others that I am from a child care home [Udayan Ghar]?

Source: QANCC (2018–19)

Appendix 6

Mean Scores of Overall Needs by Age Groups

Age of child	2012–13	2013–14	2014–15	2015–16	2016–17	2018–19
Mean Score- 10 years	3.4	3.3	3.0	3.3	3.3	3.25
Mean Score- 11 years	3.3	3.4	3.1	3.1	3.3	3.20
Mean Score- 12 years	3.4	3.3	3.0	3.1	3.3	3.08
Mean Score- 13 years	3.6	3.1	3.1	3.1	3.2	3.27
Mean Score- 14 years	3.5	3.1	3.0	3.2	3.3	3.21
Mean Score- 15 years	3.5	2.8	3.1	3.1	3.3	3.25
Mean Score- 16 years	3.6	3.4	3.1	3.1	3.1	3.27
Mean Score- 17 years	3.5	3.3	3.0	3.0	3.3	3.25
Mean Score- 18 years	3.5	3.1	3.3	3.0	3.3	3.24

Source: Generated from primary data collected using QANCC (2012–19)

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.