Research Article - Current Pediatric Research (2023) Volume 27, Issue 3

Assessment of physical and psychosocial wellbeing among preschool age orphan children.

Sara Adel Zaki^1*, Ghada Mohamed Mourad², Safaa Salah Ismail³

¹Department of Nursing, British University in Egypt-BUE, Cairo, Egypt

²Department of Psychiatric Mental Health Nursing, Ain Shams University, Cairo, Egypt

³Department of Pediatric Health Nursing, Helwan University, Helwan, Egypt

Corresponding Author:

Sara Adel Zaki
Department of Nursing, British University in Egypt-BUE, Cairo, Egypt
E-mail: sara.a.elbarbary@gmail.com

Received: 27 February, 2023, Manuscript No. AAJCP-23-89177; Editor assigned: 01 March, 2023, Pre QC No. AAJCP-23-89177(PQ); Reviewed: 10 March, 2023, QC No. AAJCP-23-89177; Revised: 20 March, 2023, Manuscript No. AAJCP-23-89177(R); Published: 30 March, 2023, DOI:10.35841/0971-9032.27.03.1817-1824.

Abstract

Background: Growing up in institutional homes and losing the nature structure of the family can lead to physical, intellectual and psychosocial developmental delay among orphan children.

Aim of the study: The current study aimed to assess physical and psychosocial wellbeing among preschool age orphan children.

Research design: A descriptive design was utilized to conduct the current study.

Setting: The study was conducted at four orphanages in Helwan district.

Sample: A purposive sample of 50 preschool age orphan children and 31 caregivers were selected based on inclusion criteria.

Tools: Three tools were used for data collection: PPSC observation checklist for psychosocial components assessment, BECSA questionnaire for children’s caregivers to assess the behavioral and emotional wellbeing of orphan children, and physical wellbeing assessment checklist to assess children’s physical wellbeing.

Results: The study showed that more than half of children (58%) had average psychosocial wellbeing. Most of children (98%) at risk of having behavioral and emotional problems. More than half of children (68%) had good physical wellbeing.

Conclusion: Majority of studied preschool orphan children had average psychosocial wellbeing and had good physical wellbeing. Additionally, there was a significant relation between psychosocial wellbeing components and physical wellbeing.

Recommendations: Continuous educational program for caregivers to provide orphan children with emotional and social support to enhance their psychosocial wellbeing, regular psychological counseling to assess the needs of orphan children for prevention and early detection of any psychosocial problem.

Keywords

Physical wellbeing, Psychosocial wellbeing, Preschool age orphan children

Introduction

Orphan children have been defined by UNICEF as the children who have one or both parents died before the age of 18 years old. Child who loss one parent is defined as single orphan while child loss both parents defined as double orphan [1]. Growing up in institutional homes and losing the nature structure of the family can lead to physical, intellectual and psychosocial developmental delay among orphan children. Living in orphanages expose children to many forms of discrimination such as social stigma during their life in orphanages and even after leaving it. As orphanages are the main option for orphan children to raise in, so it is important to assess the risks that may contribute with their normal growth and development and try to eliminate them [2].

Orphan children have poor health; reduce cognitive and emotional development, decrease physical growth and a high school dropout rate compared with non-orphan children. Comparing orphan children with non-orphans, orphans are more likely to have stunting, underweight and wasting [3].

Institution upbringing has a negative impact on the growth of children of 1-6 years of age. In children aged from 1 to 6 years who are healthy but live in orphanages there is a marked tendency to lag behind in normal development process. The above-mentioned confirms the opinion about negative impact of upbringing in orphanages on the physical development of children [4].

Concerning the importance of environment and social stability, orphan children may experience different physical and psychosocial outcomes in comparing with non-orphaned children. The negative impact of orphan on children's physical, psychological and social status has been discussed in many studies. These impacts include stunting, underweight and wasting, mild to severe depression and anxiety. Orphans have disturbed interactions and social level with others [3,5]. There are 153 million orphan children worldwide. Egypt has about 1.7 million orphan children [6].

There are some effort done worldwide and in Egypt to study the physical and psychosocial aspects of orphans but there is a lack of evidence that specify the early stages of life prior to the school age. Selecting the age group of preschool will help in linking the result to the orphanage environment rather than being general which will be difficult to identify whether the results influenced by the orphanage or school environment. For that, any future interventions will be targeted the caregivers in the orphanages. Assessing children physical and psychosocial wellbeing will assist in identifying risks on child's health status that lead to benefit children and caregiver from early interventions to catch-up the normal physical and psychosocial wellbeing pattern.

Aim of the study

This study aims to assess physical and psychosocial wellbeing among preschool age orphan children.

Research questions:

• Do preschool orphan children at risk of having physical problems?

• Do preschool orphan children at risk for developing psychosocial problems?

• Is there a relationship between the physical and psychosocial wellbeing of preschool orphan children?

Methodology

I-Technical items

The technical item includes the research design, settings, subject and tools for data collection.

Research design: Descriptive research design utilized in conducting this study.

Research settings: Study was conducted in Helwan district; four orphanages were selected to conduct the research.

Research subjects

A purposive sample of 50 preschool age orphan children and 31 caregivers living in the pre mentioned four orphanages that were matching with the inclusion criteria and accepted to be participated in the study.

Inclusion criteria: Orphan children who live in institutional home and their direct caregiver, orphan children who loss one or both parents, children age 3-6 years old (preschool age), both sex children and children with no mental and physical limitations

Tools of data collection: Three tools were utilized in this study and organized as the following:

Tool (I): An Observational Checklist: Preschool Pediatric Symptom Checklist (PPSC) is a social/emotional screening instrument was adapted and modified by researcher after reviewing related evidences to be completed by researcher as observational checklist. It contained two parts in English language.

Part (1): Socio demographic data: That aimed to assess orphans’ personal data that include child name, age, orphan classification, gender, age when admitted to orphanage, residence period, present of siblings, and relatives visit.

Part (2): Psychosocial wellbeing components: That aimed to assess orphan children psychosocial wellbeing which contained 47 questions, 19 related to personal and emotional wellbeing, 18 related to social and interpersonal wellbeing, and 10 questions related to ability to cope.

Scoring system:

Total score is described as follows:

• Poor psychosocial wellbeing if total score less than 50%

• Average psychosocial wellbeing if total score from 50%-70%

• Good psychosocial wellbeing if total score more than 70%

(7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,30,31, 38,39 are negative items/reverse-scored items)

Tool (II): Structured interview questionnaire for caregivers: Brief Early Childhood Screening Assessment (BECSA) is a screening tool for assessing early childhood behavioral and emotional wellbeing that could help in identifying young children at risk for psychosocial problems with needs for further systematic evaluation of their problems and to prevent maladaptive developmental pathways. BECSA was adapted and used as a questionnaire in Arabic language of two parts to be completed by caregivers.

Part (1): Socio demographic data: For caregivers that aimed to assess the personal data for caregivers that contained caregiver name, age, gender, level of education, working system, duration of employment, work nature, working hours, and child name.

Part (2): Behavioral and emotional wellbeing: Assessment for orphan children that contained 22 questions to assess the risk of behavioral and emotional problems. Additionally, it had one questions for caregivers’ concern regarding the child's behaviors and emotions.

Scoring system:

Brief early childhood screening assessment: The sum of the numbers for the elements from 1 to 22, with a maximum score of 44. A score equal to or greater than 9 indicates that a child may be more likely to have a mental health problem.

• Normal if total scores less than 9.

• At risk if total score equal or more than 9.

Tool (III): Physical wellbeing assessment checklist: Assessment of physical wellbeing checklist was designed to assess the growth measurements, physical status and accidences occurrence among orphan children. The tool was adapted and used in English language form that was completed by researcher. The checklist consisted of four parts.

Part (1): Growth measurements: Aimed to assess child’s height, weight and body mass index.

Part (2): Physical status assessment: That aimed to assess the child’s physical condition which includes eleven items for assessing physical status in addition to one question regarding to the presence of chronic conditions and other related to regularity of medical care.

Part (3): Accident occurrence: That aimed to assess the incidence of accidents among orphan children that contains six items regarding different types of accidences.

Part (4): Environmental safety: That aimed to assess the safety measures which established in the living environment to protect the child from any harm which contains ten items.

Growth measurements were included weight, height and BMI. Based on the child age and compared to standard measurements values for same age group, score "0" was given for abnormal weight, height and BMI. Score "1" was given to normal measurements values.

For physical wellbeing assessment which had 11 items with 3 answers for each, answer of "good" scored "2", answer of fair scored "1" and answer of poor scored"0". When total score was "0" considered poor, when total score was "11" considered fair and when total score was "22" considered good.

Total score is described as follows:

• Poor physical wellbeing if the total scores less than 50%.

• Average physical wellbeing if the total scores from 50%-70%.

• Good physical wellbeing if the total scores more than 70%.

Tool validity: The adapted tools were evaluated by a group of three experts in pediatric health nursing and mental health nursing to assess the content validity, accuracy, clarity and relevance of the tools. Required modifications were applied based on the experts’ revision and remarks. Modifications included adding more items and restructured of some parts in the tools to come up with the final version. Tools were approved as valid by experts.

Tool reliability: Cronbach’s Alpha test used to test reliability of proposed tools through SPSS computer package. It was 0.75 for “Preschool pediatric symptoms checklist”, 0.81 for “Brief early childhood screening assessment” and 0.76 for “Assessment of physical wellbeing checklist”.

Operational items

The operational items included preparatory phase, pilot study and fieldwork.

Preparatory phase: It included reviewing of current and past, national and international related literatures and theoretical knowledge of various aspect of the study using books, articles, periodical magazines and internet to modify tool for data collection. During preparatory phase, the investigator visited the selected places to get acquainted with the personnel and the study settings. Development of the tools was under supervisors’ guidance and experts’ opinions were considered.

Pilot study: A pilot study was carried out on 10% of the study sample (5 preschool orphan children and 3 caregivers who provided five responses for selected five children) to test the applicability, feasibility clarity of questions and time needed to complete the study tools by the researcher and each subject. According to the results of the pilot, no corrections and omissions of items were performed, so the children and caregivers were included in the study sample.

Field work: Field work had been conducted and data were gathered through six months. Firstly, the researcher met with orphanages’ managers at the previously stated settings and explained the aim of the study and how data will be obtained. After that, researcher met with the study participants and introduced everything about the study and their role. Explaining the questionnaire items and individual interview had been done after they signing informed consent. Researcher breaks the stranger anxiety with orphan children through playing and simple explanation in order to complete the data collection for physical and psychosocial assessment. The researcher was visiting the study settings two days per week (Sunday and Monday from 9:00 AM to 14:00 PM.

Questionnaire was completed by the caregivers who take 15-30 minutes. Researcher completed the checklist regarding physical wellbeing assessment within 20-30 minutes. Checklist regarding psychosocial wellbeing components took from 30 to 45 minutes after periodic observation of children. The researcher did not encountered limitations during data collection.

Administrative item

Official letter that approved by the dean of faculty of nursing Helwan university combined with the protocol and data collection tools were send to ministry of social solidarity for security approval. After that, approval from directorate of social solidarity in Cairo was received and referred to social solidarity administration in Helwan. Used appropriate channels of communication with authorized personnel. After receiving a written permission, individual interviewing was done after obtaining caregivers’ consent to participate. Gathered the necessary data for study after a concise explanation of the aim of study and its predictable outcomes.

Statistical analysis

Data collected from the studied sample was revised, coded and entered using Personal Computer (PC). Computerized data entry and statistical analysis were fulfilled using the Statistical Package for Social Sciences (SPSS). Data were presented using descriptive statistics in the form of frequencies, percentages. Chi-square test (χ²) Standard deviation.

Significance of the results:

• Highly significant at p-value<0.01.

• Statistically significant was considered at p-value<0.05

• Non-significant at p-value ≥ 0.05

Results

This Table 1 showed that, more than one quarter of the orphaned children (28%) are at age 5 years with a mean age of 4.5 ± 1.129, all orphans are loss both parents, more than half (62%) are male, more than three quarter (82%) of them are at age 2 years on admission, nearly to three quarter (70%) are living in orphanage for 1–3 years, and all of them not having sibling nor relatives visit.

Table 1. Distribution of socio-demographic characteristics of the orphaned children (No=50).

This Table 2 showed that, more than one quarter of the caregiver (35.5%) are at age group <30 years with a mean age of 34.5 ± 8.42, more than three quarters of them (77.4%) are female, half of them (51.6%) have below average qualification, they are all set, while more half of them (61.3%) are employed for more than 4 years, half of them (51.6%) working as direct caregiver, and most of them (87.1%) work 8 to 12 hours a day.

Table 2. Distribution of caregivers’ personal data (No=31).

Figure 1 Showed that, more than half of the orphaned children (58%) have average psychosocial wellbeing.

Figure 1: Total distribution of psychosocial wellbeing components among orphaned children (no=50). Note: %: (); No: ().

Figure 2 shows that, most of orphaned children (98%) at risk of having behavioral and emotional problems.

Figure 2: Total distribution of Behavioral and Emotional wellbeing of the orphan children based on caregivers’ responses (no=50). Note: At risk 98%: (); Normal 2%: ().

Figure 3 showed that, more than half of orphaned children (68%) have good physical status.

Figure 3: Total distribution of physical wellbeing of orphaned children (No=50). Note: %: (); No: ().

Table 3 showed that, there is a significant relation between psychosocial wellbeing components (personal/emotional, social/interpersonal, and ability to cope) and physical status of orphaned children (p-value<0.05).

Table 3. Relation between psychosocial wellbeing components and physical status of orphan children.

This Table 4 showed the relation between socio-demographic characteristics of orphaned children and their emotional wellbeing, it reveals that there is a statistically significant relation between emotional wellbeing and both orphans’ age and gender (p-value<0.05).

Items	Emotional/personal wellbeing							Chi-square
	Poor		Average		Good		Total		p-value	Sig.
	No.	%	No.	%	No.	%
Age
3 years	9	18%	1	2%	3	6%	13	13.05	0.04	S
4 years	6	12%	5	10%	0	0%	11
5 years	7	14%	1	2%	6	12%	14
6 years	5	10%	5	10%	2	4%	12
Gender
Female	12	24%	1	2%	6	12%	19	6.23	0.04	S
Male	15	30%	11	22%	5	10%	31
Age on admission
2 years	24	48%	10	20%	7	14%	41	3.39	0.18	NS
3 years	3	6%	2	4%	4	8%	9
Residence period
<1 years	5	10%	0	0%	1	2%	6	3.05	0.54	NS
1-3 years	18	36%	9	18%	8	16%	35
>3 years	4	8%	3	6%	2	4%	9
Note: HS: High Significant; S: Significant; NS: No Significant.

Table 4. Relation between socio-demographic characteristics of orphan children and their emotional/personal wellbeing.

Discussion

Assessment of child wellbeing is important as it helps in determine how the child is coping in the life. Areas of improvement can be identified through measuring the child wellbeing which allows early interventions for improving the child wellbeing. Child physical health and safety is one of the important indicators for child’s wellbeing that include the assessment of morbidity rate, obesity rate, frequency of injury, exercise and activity level. Additionally, emotional development, relationships and social behaviors are as significant as physical wellbeing assessment. Assessment of these areas with considering the variations between each child is key indicators for child’s wellbeing [7].

The findings of this study revealed that the majority of studied children more than one quarter were at the age of 5 years old with mean SD 4.5 ± 1.129. Result is similar to the study applied by Tesfaye, et al. [8] in Southern Ethiopia, which titled (factors associated with childhood underweight among orphaned preschool children: A community-based analytical cross-sectional study in Southern Ethiopia) that mentioned the majority of studied children were in age category 48–59 months (4-5 years) with a mean age of 42.55 months. The previous result is conversely to the result of the study done by Feleke, et al. [3] which titled (Undernutrition and associated factors in orphan children aged 6–59 months in Gambella Southwest, Ethiopia: A community-based cross-sectional study) that stated mean (± SD) age of children was 32 (± 15) months, and the majority of orphans 55.1%, were in the age group of 24–59 months.

The researcher considered that the study populations at preschool age from 3 to 6 years, so the majority at 5 years old is reasonable to the selected age group. Regarding the orphan classifications, the study results found that 100% of studied preschool orphans’ children are both parents orphaned.

The study result is similar with the study conducted by Feleke, et al. [3] which mentioned that the majority of 346 (84.4%) orphans were double orphans. This result is contrariwise to the study result that done by Tesfaye, et al. [8] that stated 56% of children are maternal orphans, 25.5% are paternal orphans and 18.6% are double orphans. The researcher point of view is that all the studied population are placed in orphanages as a result of abandonment that is why children are considered orphans of both parents because there were unknown biological parents.

According to the current result the majority of children 62% are male, this result is similar to the study done by Huynh, et al. [9] in Cambodia, India, Kenya, Tanzania, and Ethiopia, titled (Factors affecting the psychosocial wellbeing of orphan and separated children in five low- and middle-income countries: Which is more important, quality of care or care setting?) that presented the majority of studied sample 56.7% were male. On the other hand, the study result is contrary with the study result that showed by Hakeem, et al. [10] in Egypt, titled (Behavioral and emotional problems among institutionalized orphans children) found that 66.7% of studied sample were female. The researcher point of view is that the gender number different because children are usually transferred from orphanage to another or adopted by families so it is not consistent.

Related to the age of admission, the current study result showed that 82% of children admitted at age 2 years old with mean SD ± 2.2. The present study result is parallel to the study that mentioned previously which done by Abdel Hakeem, et al. [10] that stated, the majority of children more than half (61.7%) were admitted to orphanages at 1 ≤ 5 years. The result is opposite to the study result done by Kaur, et al. [11] in India, titled (A descriptive study on behavioral and emotional problems in orphans and other vulnerable children staying in institutional homes) which presented the majority of ages on admission to the institutional home were (53.3%) was between 5 and 10 years. The researcher point of view that most of children are adopted by families at the first two to three years of life then returned back to orphanages and this could be one of the reasons of their impaired psychosocial wellbeing.

The current study revealed that the majority of preschool orphans’ children 70% have residence period in orphanages for 1-3 years. The result consistent with the study done by Hakeem, et al. [10] which mentioned that near to half of sample duration of stay in hostel institution 33.3% 1 ≤ 5 is years. The study result is opposite to Bakari, et al. [12] in Kenya, that titled (Childcare practices, morbidity status and nutrition status of preschool children (24-59 months) living in orphanages in Kwale county, Kenya) that revealed the majority of children (67.3%) duration of stay in months is >36 months (more than three years). The researcher point of view that, in the current study the majority of children are given to family to take care of them at the first 2-3 years of life that return back to orphanages. For that the resident period for most of preschoolers at orphanages is 1-3 years.

Current study revealed that, 100% of children have no siblings. The result is similar to the result presented by Pasupula, et al. [13] in India, titled (Depression and behavior problems among children residing at welfare hostels and orphanages) founded that, and all children 100% raised in orphanages have no siblings. This result contradicts with Hakeem, et al. [10] study which stated that 48.3% of orphaned children have siblings while 51.7% have no siblings. The researcher point of view is that all children in the pre-identified study settings are placed to the orphanages by abandonment and they do not have legal parents or known families.

Related to caregivers age, the current study showed that, more than one quarter of the caregiver (35.5%) are at age group<30 years with a mean age of 34.5 ± 8.42. This result similar to the study done by Bakari, et al. [12] in Kenya which mentioned that the majority of caregivers age (93.3%) between 23-50 years with mean SD age 36 ± 8.72. The study result is opposite to the study done by Bettmann, et al. [14] in Ghana, titled (Orphanage staff’s perceptions of children’s psycho-social needs) that showed that average age of caregivers is 40.4 years. The researcher point of view that caregiver’s age from 30-40 years old is appropriate to care for children in that age group.

The current study revealed that the gender of caregiver was more than three quarters of them (77.4%) are female. Result is consistent with Tesfaye, et al. [8] in the study titled (Burden and predictors of underweight among preschool orphan children in Southern Ethiopia) that showed the majority of caregivers 94.7% were female. The result conflicting with Hlatywayo, et al. [15] study that titled (Challenges of copying with orphans and vulnerable children at household level: A caregivers perspective) which mentioned that the majority of caregivers 20 (70%) were males while female caregivers were 10(30%). The researcher point of view that the female caregivers for children in preschool age are more effective in providing children with basic needs such as feeding, dressing, bathing compared with male caregivers.

Related to education level, the present study confirmed that more than half of caregiver (51.6%) has below average qualifications. This result parallel to the study done by Bakari, et al. [12] which mentioned that the majority of caregiver (57.8%) level of education is secondary school. The current study result is opposite to the study result that done by Feleke, et al. [3] that confirmed the majority of caregivers (49%) have no formal education. The researcher point of view that most of orphanages depends on donation and paid low salary for caregivers, for that, orphanages are not attractive working environment for individuals with higher qualifications.

Regarding the whole psychosocial wellbeing components, the present study showed that, more than half of orphaned children (58%) have average psychosocial wellbeing. That result in the same line with study result published by Kyaruzi, et al. [16] in Tanzania, titled (Psychosocial wellbeing of orphaned children in selected primary schools in Tanzania) which confirmed that orphan children were facing psychosocial difficulties at a rate of 30.8%. The study result is controversy with Hailegiorgis, et al. [17] titled (Psychological wellbeing of children at public primary schools in Jimma town: An orphan and non-orphan comparative study) mentioned that among 370 studied population children 185 (50%) were orphans and among orphaned children, only 62 (33.5%) scored high on the total psychological wellbeing scale. The researcher point of view is that although majority of children have average psychosocial wellbeing, interventions still needed to improve the psychological wellbeing to be in good status.

Regarding the behavioral and emotional wellbeing, the current study showed that, most of orphaned children (98%) at risk of having behavioral and emotional problems. The current result is similar to Amare, et al. [18] in Ethiopia, titled (Psychosocial problems, coping strategy and resilience of orphaned and nonorphaned vulnerable children in selam primary school) that 100% of respondents have psychosocial problems. The study result is contrary with the result showed by Pasupula, et al. [13] in the study titled (Depression and behavior problems among children residing at welfare hostels and orphanages) that 8.3% of the study group who raised at orphanages have Rutter’s score ≥ 9 that indicate behavioral and emotional problems. The researcher point of view that result which obtained from caregivers’ questionnaire corresponding with the observation assessment of children that indicate most of them have average psychosocial wellbeing that highlighting children risk for any psychosocial problems.

The study showed that, more than half of orphaned children (68%) have good physical status. The study result is similar to Ganesan, et al. [19] titled (Health and nutritional status of orphan children’s living in orphanages with special reference to District Anantnag) that mentioned approximately (47%) of orphaned children were normal on clinical physical examination. The study result was controverted with Navpreet et al. [20] at Ludhiana, titled (Physical health problems and psychological well-being among orphan children of selected orphanage homes) that mentioned most of orphan children (91%) of the orphan children reported various types of physical health problems while 9% did not report any type of physical health problem.

The study showed that, there is a significant relation between psychosocial wellbeing and physical wellbeing of orphaned children (p-value<0.05). The result is like the study result done by Navpreet, et al. [20] which presented that found BMI (for females) was found to be significant with psychological wellbeing at (p=0.05), whereas BMI (for males) was found to be non-significant with psychological well-being at (p>0.05). The result is opposite with Malla, et al. [21] study that titled (Malnutrition and psychosocial dysfunction among the orphan and vulnerable children in Kaski district, Nepal) which found no association between malnutrition status and psychosocial dysfunction by both caregiver’s perspective and children’s own assessment (p<0.05) p=0.61. The researcher point of view that the psychosocial wellbeing could be affected by physical wellbeing as it may influence children self-esteem and body image.

Conclusion

More than half of preschool age orphan children had average psychosocial wellbeing. Based on the caregivers’ responses about children’s behavioral and emotional wellbeing, most of orphaned children at risk of having behavioral and emotional problems. In relation to physical wellbeing, more than half of children had good physical wellbeing. Moreover, there was a significant relation between psychosocial wellbeing and physical wellbeing. Finally, the study result answered the research questions. The researcher point of view is that in many institutional homes, the care provided is basically focus on biological needs such as nutrition, primary health care and basic education rather than psychosocial needs.

Recommendations

Continuous educational program for caregivers to provide orphan children with emotional and social support to enhance their psychosocial wellbeing. Regular psychological counseling to assess the needs of orphan children for prevention and early detection of any psychosocial problems. The current research suggested assessing the caregiver health wellbeing that includes physical and psychosocial wellbeing to determine their eligibility to care for orphan children. Additionally, assessing caregiver’s knowledge and practice regarding psychosocial support for orphan children.

Ethical Considerations

An official approval to conduct the planned study obtained from the scientific research ethics committee at faculty of nursing Helwan university. Participation in the study was voluntary and caregivers were provided with complete full information about the study and their role before signing the informed consent to be participated in the study and because they were the legal guard of the children. The ethical considerations included explanation of the purpose and nature of the study, stating the possibility to withdraw at any time, confidentiality of the information where it will not be accessed by any other party without taking permission of the legal guard of the children and caregivers. Ethics, values, culture and beliefs were respected during the study.

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