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Clinical Research Article
Open access
Published: 26 May 2021

Family environment and development in children adopted from institutionalized care

Margaret F. Keil 1 ,
Adela Leahu 1 ,
Megan Rescigno 2 ,
Jennifer Myles 3 &
Constantine A. Stratakis 1

Pediatric Research volume 91 , pages 1562–1570 ( 2022 ) Cite this article

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After adoption, children exposed to institutionalized care show significant improvement, but incomplete recovery of growth and developmental milestones. There is a paucity of data regarding risk and protective factors in children adopted from institutionalized care. This prospective study followed children recently adopted from institutionalized care to investigate the relationship between family environment, executive function, and behavioral outcomes.

Anthropometric measurements, physical examination, endocrine and bone age evaluations, neurocognitive testing, and behavioral questionnaires were evaluated over a 2-year period with children adopted from institutionalized care and non-adopted controls.

Adopted children had significant deficits in growth, cognitive, and developmental measurements compared to controls that improved; however, residual deficits remained. Family cohesiveness and expressiveness were protective influences, associated with less behavioral problems, while family conflict and greater emphasis on rules were associated with greater risk for executive dysfunction.

Conclusions

Our data suggest that a cohesive and expressive family environment moderated the effect of pre-adoption adversity on cognitive and behavioral development in toddlers, while family conflict and greater emphasis on rules were associated with greater risk for executive dysfunction. Early assessment of child temperament and parenting context may serve to optimize the fit between parenting style, family environment, and the child’s development.

Children who experience institutionalized care are at increased risk for significant deficits in developmental, cognitive, and social functioning associated with a disruption in the development of the prefrontal cortex. Aspects of the family caregiving environment moderate the effect of early life social deprivation in children.

Family cohesiveness and expressiveness were protective influences, while family conflict and greater emphasis on rules were associated with a greater risk for executive dysfunction problems.

This study should be viewed as preliminary data to be referenced by larger studies investigating developmental and behavioral outcomes of children adopted from institutional care.

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Introduction.

The science of early childhood development is clear about the importance of early experiences, caregiving environment, and environmental threats on biological, cognitive, and behavioral development. Young children exposed to institutionalized care, which often corresponds with social deprivation and low caregiving quality, have an increased risk for behavioral problems and psychopathology. 1 , 2 , 3 , 4 , 5 , 6 Intervention studies of children who experienced institutionalized care and are later adopted or placed into foster care provide evidence that a more favorable caregiving environment may lead to improved outcomes in growth, health, and development, and an overall reduced risk for psychopathology 7 , 8 , 9 , 10 , 11 and may reverse the negative effects of early deprivation on hypothalamic pituitary axis functioning and neurobehavioral development. 8 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20

Prior studies have addressed the effects of institutionalized care on neurodevelopment and identified significant deficits in cognitive and social functioning, and developmental delay in children adopted post institutionalization. 3 , 5 , 6 , 8 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 Age at adoption and time spent in institutionalization are associated with significant and often detrimental effects on overall outcomes. 21 , 22 Institutionalized care and accompanying stimulus deprivation affect the development of the prefrontal cortex. 23 , 29 , 30 , 31 , 32 , 33 , 34 , 35 The prefrontal cortex has a key role in the development and regulation of executive functions as well as the control of the autonomic system balance. Executive functions refer to a group of higher-order cognitive processes that coordinate the planning and execution of thoughts, emotions, and behaviors, as well as the storage of information in working memory. 36 , 37 , 38 , 39 Executive skills are critical building blocks for the early development of cognitive and social capabilities; the gradual acquisition of these skills correspond to the development of the prefrontal cortex and other brain areas from infancy to adulthood. 36 , 37 , 38 , 39

There is a paucity of research about post-adoption parenting styles that may promote recovery in children after institutionalized care. Ample evidence supports that the early caregiving environment is a consistent predictor of developmental outcomes and executive skills. 40 , 41 , 42 , 43 , 44 The developing executive function system is influenced by a child’s experiences, response to stress, and structural and molecular changes associated with changes in the hormonal milieu in the brain during sensitive periods of development. Dehydroepiandrosterone (DHEA) has a critical role in human brain development and cognition likely due to the effects of this steroid in enhancing brain plasticity. 45 , 46 Results of recent studies suggest that DHEA affects the development of cortico-amygdala 46 and cortico-hippocampal functions 47 that are important to encoding and processing of emotional, spatial, and social cues, as well as attention and working memory processes. In addition, steroids that are DHEA precursors, such as progesterone and allopregnanolone, have critical roles in neuroprotection. 36 , 37 , 38 , 39

In this prospective study, we followed the development of children who experienced institutionalized care 2 years post adoption by a family in the United States. We examined the relationship between family environment, growth, endocrine and levels of neurosteroids, executive functioning, and cognitive development in children adopted from institutionalized care and non-adopted controls to identify factors related to developmental recovery and behavioral outcomes.

Participants

We recruited children adopted from institutionalized care in Eastern Europe within 2 months of adoption by a US family. Eligible participants had no history of significant medical, developmental, or behavioral problems. Participants were screened to determine that they spent at least 8 months in the institution/orphanage setting and were placed in the institution/orphanage at 6 months of age or less. Participants were recruited from local adoption referral centers. Child participants were recruited for a control group and were cohort age–sex-matched with the adopted subjects. The controls were healthy children with no history of significant medical, psychological, or behavioral disorders. Exclusion criteria for the study included documented history of growth hormone deficiency, history of chronic illness (i.e., renal failure, chronic lung disease, diabetes, hypothyroidism, chromosomal abnormalities, medical conditions known to be associated with developmental delay (i.e., fetal alcohol syndrome (subjects were screened using criteria developed by Hoyme et al. 48 )) chronic infectious disease (e.g., AIDS, hepatitis), or precocious puberty. Socio-economic scores were similar between groups.

Participants were seen at baseline (within 2 months of arrival in the United States for adopted subjects) at 1- and 2-year follow-up. All studies were conducted under protocol 06-CH-0223 that was approved by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Institutional Review Board. Informed consent was obtained from the parent/legal guardian. A total of 11 adopted children and 27 controls were recruited. Ten adopted children and 19 controls completed at least two follow-up visits and were included in the analysis. The study was closed to recruitment earlier than anticipated due to the suspension of adoptions from Eastern Europe to the United States.

Anthropometric measurements, physical examination, neurocognitive testing, behavioral questionnaires, and endocrine labs and bone age (adopted children only) were evaluated over a 2-year period. Anthropometric measures included height, weight, body mass index (BMI), mid-arm circumference (MAC), triceps skinfold (TSF), subscapular skinfold (SSF), waist circumference (WC), and occipitofrontal circumference (OFC) by a registered dietitian.

Due to the participants’ age and ethical issues related to procedures that expose healthy child participants to risk, blood and bone age x-rays to assess nutritional and endocrine status were obtained for adopted children only (along with clinically indicated laboratory tests). Serum cortisol, DHEA, testosterone, estradiol, and serum neurosteroid profile were also collected (convenience sample: between 11 a.m. and 1 p.m.).

Neurocognitive testing was performed by a pediatric neuropsychologist and included either the Bayley III or Differential Abilities Scale II (DAS) based on age-appropriate guidelines. Behavioral questionnaires included Child Behavior Checklist (CBCL), Behavior Rating Inventory of Executive Function- Preschool (BRIEF-P), Infant Toddler Social Emotional Assessment (ITSEA), Colorado Child Temperament Inventory (CCTI), and Family Environment Scale (FES). Waters Attachment Behavior Q-sort (AQS) assessment of child attachment (Waters, SUNY) was performed by two trained observers at the initial visit.

The Bayley III is a clinical evaluation by a trained clinician to identify developmental issues in infants and toddlers and consists of the following domains, adaptive behavior, cognition, language, motor skills, and social–emotional capacities. Mean scores for scales are 10, with an SD of three. 49 The DAS is a nationally normed (US) battery of cognitive and achievement tests for children aged 2 years 6 months to 17 years 11 months across a range of developmental levels; mean is 100, SD of 15. 50 The CBCL questionnaire is a validated parent-report measure to assess emotional (internalizing and externalizing symptoms) and maladaptive behavior in children. 27 The BRIEF-P is a reliable, valid parent-report inventory to assess executive function in preschool children; our analysis focused on the clinical scales of: inhibit (control behavioral response), shift (ability to alternate attention), emotional control (regulate emotional responses), working memory (ability to hold information when completing a task), plan/organization (to plan, organize), and Global Executive Composite (GEC). Scores on the CBCL and BRIEF-P are normalized to a mean of 50 (SD 10), with higher scores indicative of greater degrees of dysfunction and scores >65 considered to be clinically significant. 51 ITSEA is a validated measure completed by the parent to assess social–emotional problems and competence in children (1–3 years of age) and is comprised of four domains, externalizing (impulsive, aggression), internalizing (depression, anxiety, separation distress, inhibition to novelty), dysregulation (sleep problems, negative emotions, sensory sensitivity), and competence (attention, compliance, play, mastery, empathy, prosocial peer relations). 52

The CCTI is a validated inventory designed to assess the temperament of children by parental report. 53 The FES is a self-reported questionnaire to assess social climate and environmental family characteristics and family functioning and emotions. The FES is categorized into three domains with ten subscales—relationship dimensions (cohesion, expressiveness, and conflict), personal growth dimensions (independence, achievement orientation, intellectual–cultural orientation, active–recreational orientation, and moral–religious aspect), and system maintenance dimensions (organization and control). 54 The AQS is widely used to assess child attachment behavior and is based on Ainsworth’s study of secure attachment behavior in infants. The AQS assesses the correlation between secure attachment type and child–parent boundaries and has high validity. The AQS security score is the correlation of a specific child’s Q-sort to prototypical secure child and the score range is from −1.0 to +1.0. 55 , 56

We hypothesized that aspects of the family environment, as measured by FES, would be associated with outcome measures of cognitive, executive function, and behavioral problems.

Statistical analysis

To compare children of different ages, anthropometric measurements, and cognitive function scores were converted to z -scores (the difference between the child’s measurement/score and the age mean or the mean provided by standardized cognitive test, divided by the standard deviation (SD)). For length, height, weight, BMI, OFC, MAC, TSF, SSF, and WC z -scores were calculated using the program PediTools, 57 based on means for age and SDs obtained by the National Health and Nutrition Examination Survey (Center for Disease Control and Prevention (CDC)). The CDC provides a set of growth measurements that are standardized among an ethnically diverse population.

Descriptive statistics were examined, and analysis of variance (ANOVA) was conducted to evaluate group differences in growth, cognitive, and behavior problems. Statistical comparisons included paired t tests, ANOVAs, correlation, and regression analysis. Regression analyses were conducted to examine which aspects of the family environment predicted cognitive or behavioral outcome measures. Analyses were conducted using the SPSS software. A p value <0.05 was considered for statistical significance.

There was no significant age or sex difference between adopted and control groups at the initial visit (adopted: 27.5 ± 9.3 months (range 14–40 months), 6 females, 4 males; control: 30.7 ± 14 months (range 10–58 months), 9 females, 10 males). For adopted subjects, the average time spent in institutionalized care was 23.6 ± 9 months. All the adopted children in our study were engaged with early intervention educational services.

At baseline, adopted subjects had significantly lower z -scores for height/length, weight, OFC, and MAC compared to controls ( p < 0.5). At baseline, one adopted subject had height and weight z -score <2 SD, compared to one subject in the control group with weight <2 SD; six adopted subjects had OFC <2 SD compared to one control subject with OFC <2 SD. No significant differences were found for z -scores for TSF or SSF or WC. At 2-year follow-up, adopted subjects showed significant improvement in z -scores of height and weight; there were no differences between the two groups for anthropometric measures. For adopted subjects at follow-up, one child had weight SD < 2 SD and four children had OFC < 2 SD. OFC was not obtained in most control subjects at 2-year follow-up. (Table 1 ).

Endocrine and metabolic measures (adopted children)

Serum cortisol was obtained between 11 a.m. and 1 p.m. The range of cortisol levels was 4.2 to 16.3 μg/dL. Time in orphanage care was positively associated with serum cortisol at baseline ( R 2 = 0.61, p < 0.06) (Fig. 1 ). Due to the small sample size, the two outliers with longer time in orphanage care may have skewed the results; however, serum cortisol levels at follow-up were not statistically different from baseline values. We planned to collect salivary cortisol levels (diurnal) for both adopted and control subjects; however, due to poor compliance or lack of ample quantity of sample collected, there was insufficient data for analysis. At baseline, thyroid function results were within normal limits, except for one child who had mildly elevated thyroid-stimulating hormone with normal free T4, which normalized at follow-up visit. Other endocrine hormone levels were within normal limits for age/sex. Insulin-like growth factor-1 (IGF-1) and insulin-like growth factor-binding protein 3 (IGFBP3) z -scores at baseline (0.62 ± 0.2, 1.2 ± 0.3, respectively) and follow-up (0.43 ± 0.3, 1.58 ± 0.3, respectively) were within normal range. Growth factors were not a predictor of cognitive outcome. At the initial visit, bone age was consistent with chronological age in five children, advanced in three children, and delayed in two children. At follow-up, bone age was consistent with chronological age in six, advanced in two, and delayed in two children.

Cortisol levels in adopted children: time in orphanage care is positively correlated with serum cortisol at baseline ( r 2 = 0.608, p < 0.06). Serum cortisol was obtained between 11 am and 1 pm. (convenience sample). Cortisol levels ranged from 4.2 to 16.3 μg/dL.

A serum lipid panel was obtained (convenience sample, non-fasting). At baseline, serum cholesterol and low-density lipoprotein levels were within normal limits for age. Serum high-density lipoprotein levels were <40 mg/dL in six of the ten subjects, and at follow-up remained <40 mg/dL in two of the nine subjects.

Serum neurosteroids were measured at baseline ( n = 6) and follow-up ( n = 9) by isotope dilution high-performance liquid chromatography-tandem mass spectrometry. 58 Allopregnanolone levels were within the expected range for the assay and levels were similar to a recent report in a healthy population of toddlers that found no significant diurnal variation, as well as no differences between males and females, in the first 3 years of life. 59 Serum tetrahydro-11 deoxycortisol, tetrahydrodeoxycorticosterone, and DHEA levels were at the lower limit of detection for the assay and did not change in the six subjects who had both baseline and follow-up measured (Table 2 ).

Cognitive data

At baseline, adopted subjects had significantly lower scores compared to controls on all cognitive measures (Bayley III): cognitive, language receptive, language expressive, fine motor, and gross motor ( n = 9 of adopted and 10 of controls were age appropriate for testing with Bayley III). To compare changes in scores from baseline to follow-up, overall cognitive z -scores were calculated ( z -score of Bayley III or DAS General Cognitive Ability) and ANOVA analysis was performed. At baseline, general cognitive z -scores were significantly lower for adopted vs. controls; at 2-year follow-up, there was a trend for improvement in scores for adopted; however, residual differences remained compared to controls. For adopted subjects, lower OFC z -scores (baseline) were associated with lower cognitive scores at follow-up (Table 3 and Fig. 2 ).

a Comparison of mean scores on Bayley III at baseline. Adopted subjects had significantly lower scores in all subscales compared to controls. b Comparison of baseline and follow-up cognitive z -scores. Adopted subjects had significantly lower z -scores at baseline and although a trend was noted for improvement in adopted subjects’ scores from baseline to follow-up, residual differences remained. Error bars indicate standard error. * P < 0.05.

Behavioral data

At baseline, adopted children had significantly lower scores than controls for the ITSEA competence subscale ( p < 0.001; F = 19.017); lower scores are associated with lower social–emotional competence. Since most subjects were above the age limit for use of ITSEA at follow-up, these data were not included in the analysis. At baseline, adopted children had significantly higher scores on the emotional subscale of the CCTI compared to controls ( p < 0.03; F = 5.516). Baseline CBCL results showed no difference between the adopted and control group for any subscale scores. At 2-year follow-up, adopted children had significantly higher scores on externalizing symptom subscales compared to controls ( p < 0.03; F = 5.251).

For adopted subjects at baseline, parent responses for the BRIEF endorsed clinically significant inhibitory control in half the children ( p < 0.05; F = 4.424); no significant difference was found between the adopted and control groups for other subscales. At follow-up the adopted group had significantly higher scores (higher scores associated with more problems) compared to controls for the following subscales: inhibition ( p < 0.04; F = 5.027), inhibitory self-control ( p < 0.03; F = 5.328), with a trend noted for working memory and GEC (Fig. 3 ).

Comparison of mean scores on a ITSEA-Emotional Assessment (baseline); b CCTI-Temperament Assessment (baseline); c CBCL-Behavioral Assessment (baseline and follow-up); and d BRIEF-P-Executive Function (baseline and follow-up) of adopted vs. controls. Error bars indicate standard error. * P < 0.05.

Waters Q attachment scores showed no difference in attachment between adopted children and controls; AQS scores strongly correlated with norms for a sensitive response. Based on that, we concluded that there were no differences between parents’ sensitivity and child attachment in either group and their secure–insecure attachment distribution was comparable with that of normative groups (data not shown). FES scores at baseline showed a significant difference for only the independence subscale score between adopted vs. control groups ( p < 0.05; F = 4.418).

To identify sociodemographic and family environment factors associated with increased risk for executive dysfunction or behavioral problems, a correlational analysis was performed between demographic variables of child gender and age and executive function variables to determine possible covariate variables. Sex was not significantly correlated with any executive function variables and therefore not included in any future analysis. However, age at baseline was significantly correlated with BRIEF subscales; correlation and linear regression analyses were used for these executive function variables.

For adopted subjects, the baseline FES subscales control and conflict were predictors of higher GEC scores at follow-up (BRIEF measure; higher scores associated with dysfunction) ( R 2 = 0.91; F = 14.48, p = 0.03). FES subscale achievement positively correlated with change in cognitive z -scores ( R 2 = 0.433; F = 6.106, p = 0.04). FES subscales cohesion and expressiveness were negatively associated with a change in internalizing scores of CBCL ( R 2 = −0.9; p = 0.04), that is, greater cohesion and expressiveness were associated with lower scores on internalizing symptoms of CBCL. FES subscale control was a predictor of a higher internalizing score (CBCL) at follow-up ( R 2 = 0.74; F = 10.893, p = 0.03); greater emphasis on rules and procedures were associated with more internalizing symptoms, which is a reflection of mood disturbance (i.e., anxiety, depression, social withdrawal). CCTI emotionality was associated with an increase in externalizing scores of CBCL for adopted subjects ( R 2 = 0.97; p < 0.005) (Tables 4 and 5 ).

This prospective study followed the development of children adopted from institutionalized care for 2 years post adoption compared to controls. Broadly, our findings are consistent with the literature, showing significant but not complete growth and developmental recovery post adoption for children exposed to institutionalized care. Kroupina et al. 28 reported that growth factors (IGFBP3) at baseline were a negative predictor and change of head circumference and cognitive scores at 6 months were positive predictors, of cognitive outcomes at 30 months post adoption. Our data did not show a correlation between baseline growth factor z -scores and cognitive outcome at follow-up, perhaps due to the constraints of our small sample size. However, OFC z -scores at baseline were a predictor of cognitive scores at 2-year follow-up. Also, Kroupina et al. 28 reported that smaller stature at baseline and weight gain were associated with improved height outcome at 30- month follow-up, and younger age and lower weight at baseline were a predictor of better catch-up growth. Our data did not replicate the findings of Kroupina et al. 28 regarding predictors of catch-up growth, likely due to the constraints of our sample size. Baseline z -scores for height, weight, and OFC were similar between our study and Kroupina et al., 28 which had a larger sample size. As expected, there was a negative correlation between time in orphanage care and baseline height and weight z -scores. Consistent with previous studies, 8 , 21 , 24 , 26 , 34 , 60 , 61 , 62 , 63 , 64 our results support specific aspects of the family environment that are associated with executive function and behavioral symptomology 2 years after adoption. 65 , 66 Specifically, greater conflict and less flexible rules in a family were predictors of higher scores of global executive dysfunction. BRIEF scores reflect the parent’s observations of the child’s everyday executive functioning relative to the parent’s expectations (not an absolute level of functioning) and thus serve as a screening tool for executive dysfunction. Also, in this study, adopted children were found to have higher scores for behavioral inhibition, an aspect of temperament characterized as social reticence that is reported to be stable across childhood and is associated with greater risk for developing social withdrawal, anxiety disorders, and internalizing problems. Prior studies report that developmental outcomes associated with behavioral inhibition can be influenced by the caregiving context; authoritarian style (i.e., lack of emotional warmth, non-transparent declaration of rules, and high levels of control) is detrimental for social developmental outcomes. 67

Family cohesion and expressiveness were a protective influence; at 2-year follow-up, stronger family cohesion and expressiveness were associated with lower internalizing scores (i.e., less problems with mood disturbance, including anxiety, depression, and social withdrawal). Prior studies of internationally adopted children reported either higher mean internalizing symptoms or no differences in internalizing scores between adopted vs. non-adopted children. 66 , 68 , 69 Consistent with prior studies, we found higher externalizing scores (i.e., greater problems with aggression, conflict, and violation of social norms) on the CBCL at 2-year follow-up for adopted children that were associated with higher emotionality scores on CCTI. 70 Scores on the FES at baseline did not differ significantly between groups, suggesting that there were no differences in perceived family characteristics between adopted and controls. 54

As expected, at baseline visit there were significant differences in measures of cognitive function between adopted children and controls; overall mean scores improved but remained lower than controls at 2-year follow-up. Cognitive scores were negatively associated with OFC z -scores (baseline visit). At baseline, compared to controls, adopted children scored lower on measures of competence (as measured by ITSEA) and scored higher (associated with more problems) on measures of emotionality (as measured by CCTI) and inhibitory control (as measured by BRIEF). At follow-up, adopted children scored higher (associated with more problems) on measures of externalizing symptoms, inhibition, inhibitory self-control, behavioral flexibility, working memory, and GEC (BRIEF). The developing executive function system is influenced by a child’s experiences and response to stress, which impacts the developing prefrontal cortex. In this study, although the measurement of neurosteroids did not reveal any relationship to measures of cognitive or behavioral symptomology; the small sample size and lack of data in the control group limit interpretation and future research is warranted.

We did not identify differences in attachment measures in adopted vs. controls. We observed “indiscriminate friendliness” in many of the adopted subjects, as has been described in the literature. 5 , 63 Our observations are consistent with prior studies that note indiscriminate sociability in children with secure attachment. 71 , 72

The strengths of this study are the prospective design and the differentiation of behavioral issues noted at adoption placement versus those that manifest later. Limitations of the study include the small number of participants (the study was terminated prematurely due to the cessation of adoptions from East Europe). Another limitation was that measures of internalizing, externalizing behaviors, and executive function included only parental assessments of behavior. Also, the lack of salivary cortisol data (due to either inadequate quantity of samples collected or poor compliance with collection in this infant/toddler population) is regrettable since salivary cortisol levels are widely used and are an invaluable tool for pediatric studies and would have provided useful information for comparison of adopted and control subjects.

This study, in the context of a small sample size, should be viewed as a pilot study in the field of developmental pediatrics. Here we find that specific aspects of the family caregiving environment moderate the effects of social deprivation during early childhood on executive function and behavioral problems. These findings provide preliminary data for larger studies that will further investigate the developmental effects that manifest in institutionalized children.

In summary, findings from this study support a cohesive and expressive family environment moderated the effect of prior pre-adoption adversity on cognitive and behavioral development in toddlers. Family conflict and greater emphasis on rules/procedures were associated with a greater risk for behavioral problems at 2-year follow-up. Early assessment of child temperament child and parenting context may provide useful information to optimize the fit between parenting style, family environment structure, and the child’s development.

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Acknowledgements

We thank the children and their families for their participation in this study. We thank Dr. Patrick Mason (International Adoption Center, Fairfax, VA), Dr. Penny Glass (CNMC), Dr. Sharon Singh (CNMC), Dr. Pedro Martinez (NIMH), Dr. Steven Soldin (NIH CC DLM), and Dr. Moommal Shaihh (NICHD) for their assistance. We acknowledge the University of Nevada School of Medicine for support of Dr. Rescigno’s elective rotation with NICHD/NIH. This study was supported by NIH grant Z01-HD008920.

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M.F.K.: conceptualized and designed the study, coordinated and supervised data collection, drafted the initial manuscript, and reviewed and revised the manuscript. A.L. and J.M.: collected data and carried out the initial analysis and reviewed and revised the manuscript. M.R.: assisted with the analyses and reviewed and revised the manuscript. C.A.S.: conceptualized and designed the study, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Keil, M.F., Leahu, A., Rescigno, M. et al. Family environment and development in children adopted from institutionalized care. Pediatr Res 91 , 1562–1570 (2022). https://doi.org/10.1038/s41390-020-01325-1

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Adoption Studies

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Barbara Steck 2

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Research in the field of adoption has been ongoing for decades, including studies of interactions of genetic, family, and environmental influences on the psychosocial development of adopted children. Numerous variables such as age, gender, protective and risk factors are explored, as well as potential vulnerable situations that contribute to the psychosocial adjustment of adopted children or lead to psychosocial disorders. Other investigations seek to identify key differences in early versus late adopted children, in national versus international adoptions and in open adoption. Adoption is uniformly described in the literature as the best solution for the development of a child without a family, compared to institutional or foster care placement. Research findings allow a unique insight into the malleability of child development, demonstrating children’s ability to recovery from adversities in infancy. Risk or higher vulnerability are recorded among children with adverse pre- adoptive experiences such as neglect, maltreatment, or multiple placements. Most adoptees do not suffer from mental or somatic illnesses and show little or no influence of adoption on their personal development.

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Internalizing problems are characterized by anxious and depressive symptoms, social withdrawal, and somatic complaints. Externalizing problems are defined as aggressive, oppositional, and delinquent behavior.

Attachment Disorders are psychiatric illnesses that can develop in young children who have problems in emotional attachments to others (American Academy of Child Adolescent Psychiatry)

Racially different parents and children in adoptive families

The teaching of coping skills to help children deal effectively with racism and discrimination.

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Barbara Steck

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Steck, B. (2023). Adoption Studies. In: Adoption as a Lifelong Process. Springer, Cham. https://doi.org/10.1007/978-3-031-33038-4_4

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What Behavioral Genetics Teaches Us About Adoption

How nature and nurture interact..

Posted August 2, 2020

What Is Adoption?
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Behavioral genetics was founded as an interdisciplinary field in the 1970s to separate itself from any connection with genetic determinism or with eugenics. (Eugenics aspired to improve humanity through selective breeding, which led to racist and anti-Semitic policies.) The founders of behavioral genetics were mainly quantitative psychologists with no training in genetic science. That is changing now. They did not study group differences like race or ethnicity , and rarely gender . Rather, they looked only at differences in individual development and looked at both genetic and environmental forces and how they interact. They considered the environment both inside and outside the family.

What was most important to me was that they used adoptive families for their studies, comparing siblings (both adoptive and biological) within the same family and comparing families formed by adoption to biological families of the same ethnicity and social class background (called a control group). Twins separated through adoption were part of these studies done at universities in Minnesota, Colorado, Texas, Pennsylvania, Oregon, and others.

These were ethical studies, not like the secret studies described in the documentary Three Identical Strangers . All participants in behavioral genetics studies were volunteers and many stayed in the studies for 20 to 30 years. As they became teenagers and adults, the adoptees were given yearly reports on the findings. In Creole Son , I use specific studies that were relevant to the issues my son and I faced, and I integrate their findings with my experience.

For these researchers, adoption was a way to separate the impact of nature and nurture and to understand more about individual development over time. Until recently, they were not interested in adoption theory or practice. The main criticism of these studies focuses on the admitted fact that they find correlations, not causes, and some correlations are not very strong. A second major question raised about these studies is whether you can generalize from adopted families to the whole population. Here, I didn’t care, because I was only interested in what I could learn about adoption, especially my own; I wanted to create a model that those involved in adoption could use for personal understanding.

My favorite study is one that was done at the University of Colorado Adoption Project, which started in the 1970s and continued for more than 20 years. Using 13 tests of cognitive abilities, the researchers picked 245 adoptees given up at (or near) birth. They gave these tests to the birth mothers and adoptive parents, along with a control group of biological families. As the adoptees were growing up, they tested them at various ages and when they were 16, the adoptees, adoptive parents, and control group were given the same tests as their birth mothers had been given at about the same age.

The results were counterintuitive. The adoptees only had similarities with the adoptive parents in the first four years. By age 16, the adoptees had no similarities to the adoptive parents, but had developed moderate resemblance to the birth mothers, comparable to that of children who grew up in a biological family. The researchers concluded that environmental transmission from parents to offspring had little effect on later cognitive ability. A Texas study found a similar pattern in psychological characteristics, but the correlation was not as high.

This study gave me some insight into why the young boy with whom I felt so close and in tune with deviated from me as a teenager and beyond, making choices that were so different from mine. These findings mean that adoption educators should counsel parents to expect these differences. Many biological parents have the same experience, but it is more prevalent in adoptive families. One can still love a child and appreciate some of such differences, many of which may be positive, but adoptive parents cannot assume that the child will make choices or have personal characteristics like others in their family.*

*An earlier version of this post was published as part of an interview with Bella DePaulo on her blog on PsychCentral, Single at Heart .

E. Kay Trimberger, Ph.D. , is professor emerita of Women’s and Gender Studies at Sonoma State University

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Russian adoption: a brief history & what's behind the current media attention, what ended russia’s intercountry adoption program with the u.s. in 2013 and why is it generating political heat again.

Adoption News

nesting dolls from Russia; though Russian adoption by U.S. citizens has been banned, Russian adoption is currently in the news

United States citizens have been unable to adopt children from Russia since 2013, when a Moscow-instituted ban ended an active 22-year program that placed more than 60,000 Russian-born children with adoptive parents in the U.S. This is not news, however, the inactive program is receiving renewed interest and scrutiny thanks to this week’s revelations about Donald Trump, Jr.,’s meeting with a Russian attorney during the 2016 presidential campaign season. That meeting, Trump, Jr., initially said, revolved around the U.S.-Russia adoption program. But a July 10, 2017 New York Times headline stated, “ When the Kremlin Says ‘Adoptions,’ It Means ‘Sanctions ,” and we have since learned that the meeting more certainly touched on topics beyond adoption. So, what is the history of Russia’s intercountry adoption program with the U.S., and why is it such an important lynchpin in D.C.-Moscow relations?

Russian Adoption By the Numbers

Russia formalized its international adoption program in the middle of 1991. That year, 12 children were adopted by American families. That figure grew quickly, topping 1,000 children by 1994, rising to 4,292 in 2001 and reaching a peak of 5,862 adoptions in 2004. (International adoption reached an overall historic high that year, with a total of 22,884 foreign-born children adopted by U.S. families.)

Soon after, however, the number of Russian-born children adopted by U.S. families started dropping sharply year after year. Just 748 such adoptions were completed in 2012. The following year, Vladimir Putin signed a law banning U.S. families from adopting children born in Russia. The U.S. Department of State (DOS) logged 250 adoptions completed in 2013 and two in 2014—all of which were in-process before the ban—and zero thereafter.

The Russian Adoption Process

Adopting from Russia was an involved, expensive process that required two or even three international trips (or a lengthy stay). Prospective parents did not formally receive a referral before embarking on their first trip, to meet the child. On a region-by-region, or even case-by-case basis, some families would receive photos, a medical report, or even a video before traveling; other families traveled “blind.” Paperwork requirements and court procedures often varied by region, as well, and could involve extensive updating between parents’ first and second trips.

Every Russian adoption required parents to obtain their child’s visa in Moscow. Given the high cost of traveling to and staying in Russia’s capital city, this conclusion to the adoption journey added a significant time and cost. In Adoptive Families ’ 2012-2013 Adoption Cost and Timing Survey , readers reported totals of $40,000 to more than $50,000 for a typical adoption in Russia—the highest average cost for any sending country at the time.

Negative Perceptions of International Adoption in Russia

As U.S. citizens continued to adopt thousands of Russian-born children, many of whom had medical and behavioral special needs , the Russian public and lawmakers grew increasingly uncomfortable about the number of “orphans” finding homes abroad. The Russian government began tightening restrictions for adoption agencies, adopting parents, and children eligible for adoption; it also began promoting domestic adoption. These efforts were generally successful and, in 2008, more children were adopted by Russian citizens than by families in other countries. At the time, president of the adoption advocacy group Joint Council on International Children’s Services (which has since ceased operations) Tom DiFilipo said, “I think that’s a good thing for children.”

Most Russian adoptees found safe, loving homes with families in the U.S. over the duration of the country’s international adoption program. However, 19 children tragically died in the care of their adoptive families here in America. Each case was widely publicized in Russia and several prompted talks of moratoriums.

Two of the most widely publicized cases of heartbreaking deaths or mistreatments of Russian adoptees were those of Chase Harrison and Artyom Savliev. In 2008, months after Chase was adopted from Russia, the toddler died of heatstroke while left alone in a car for nine hours. His adoptive father, Miles Harrison, was acquitted in the case. As Judy Stigger, LCSW, adoption therapist and clinical director of Adoption Learning Partners at The Cradle, in Evanston, Illinois (at the time, Stigger was the agency’s director of international adoption) explained, the outrage in Russia over the death of this young child was heightened by cultural differences; the not-guilty verdict was confusing to Russians because their legal system “doesn’t allow for acquittal when something has clearly gone wrong.”

In 2010, Torry Ann Hansen put seven-year-old Artyom on a flight back to Russia with a note that read, “I no longer wish to parent this child.” Hansen has since been ordered to pay child support.

The Magnitsky Act and the Dima Yakovlev Law (Russian Adoption Ban)

On December 28, 2012, Russian President Vladimir Putin signed the Dima Yakovlev Law (Russian Federal Law No. 272-FZ), which banned U.S. citizens from adopting Russian children. The ban went into effect on January 1, 2013. At the time, several hundred families were in the process of adopting from Russia, including at least 200 who had already been matched with or met the children they were hoping to adopt.

While the law was formally named after Dima (or Dmitry) Yakovlev, the birth name of young Chase Harrison, it is generally accepted that the law was a direct retaliation for the Magnitsky Act passed by the U.S. This law, signed by President Barack Obama on December 14, 2012, froze the assets of Russians implicated in human rights abuses and denied them visas to enter the United States. It was named after a Russian lawyer, Sergei Magnitsky, who uncovered a tax fraud scheme that involved high-ranking Russian officials. Magnitsky died in Moscow in 2009, after being held in prison without trial for nearly a year. The legislation that includes the ban on Russian adoption has been commonly referred to as the “Anti-Magnitsky” law.

When news first broke of the June 9, 2016 meeting between a Russian lawyer and Donald Trump, Jr., Jared Kushner, Paul Manafort, Russian-American lobbyist Rinat Akhmetshin, and possibly others , the younger Trump claimed in a brief statement that the meeting was about adoption: “We primarily discussed a program about the adoption of Russian children that was active and popular with American families years ago and was since ended by the Russian government, but it was not a campaign issue at the time and there was no follow up.”

Less than 24 hours later, Trump, Jr., revised this claim, noting that the meeting with Natalia Veselnitskaya, a lawyer with Kremlin connections, was set up with the promise of receiving damaging information about presidential candidate Hillary Clinton. According to his account, however, “It quickly became clear that she had no meaningful information. She then changed subjects and began discussing the adoption of Russian children and mentioned the Magnitsky Act.”

This comment seems to underscore this direct link between Russian’s adoption program and U.S.-imposed sanctions, as noted in the July 10 New York Times article about Russia’s use of international adoption as leverage to encourage the U.S. to lift sanctions against Russian officials. And thus, adoption and the well-being of thousands of children were once again used as a pretense and a means to try to enact political revenge.

SOURCES: travel.state.gov/content/adoptionsabroad/en/about-us/statistics.html travel.state.gov/content/adoptionsabroad/en/country-information/learn-about-a-country/russia.html adoptionknowhow.com/russia/statistics johnstonsarchive.net/policy/adoptionstatsintl.html pbs.org/pov/firstpersonplural/history/2/ articles.latimes.com/1992-12-09/news/mn-1705_1_foreign-adoption nytimes.com/2017/07/10/world/americas/kremlin-adoptions-sanctions-russia.html nytimes.com/2017/07/09/us/donald-trump-jrs-two-different-explanations-for-russian-meeting.html nytimes.com/2017/07/08/us/politics/trump-russia-kushner-manafort.html slate.com/articles/health_and_science/explainer/2013/01/russian_adoption_ban_are_children_adopted_from_other_countries_more_likely.html forbes.com/sites/dianeclehane/2012/05/31/u-s-mother-who-returned-her-adopted-son-to-russia-ordered-to-pay-child-support/#3d5f137521f1 nytimes.com/2013/09/01/us/widening-ripples-of-grief-in-adoptees-death.html?pagewanted=all newyorker.com/news/news-desk/whats-behind-the-russian-adoption-ban businessinsider.com/magnitsky-act-russian-adoptions-donald-trump-jr-meeting-2017-7 en.wikipedia.org/wiki/Dima_Yakovlev_Law priceonomics.com/why-did-international-adoption-suddenly-end/ travel.state.gov/content/dam/aa/pdfs/2015NarrativeAnnualReportonIntercountryAdoptions.pdf travel.state.gov/content/dam/aa/pdfs/2014_Annual_Report_on_Intercountry_Adoptions_Narrative.pdf nytimes.com/2017/07/09/us/donald-trump-jrs-two-different-explanations-for-russian-meeting.html nytimes.com/2012/12/28/world/europe/putin-to-sign-ban-on-us-adoptions-of-russian-children.html

Factors influencing adoption of sexual and reproductive health intervention for adolescents in Ebonyi, Nigeria

Aloysius Odii 1 , 4 ,
Ifeyinwa Chizoba Akamike 1 , 3 ,
Chinyere Ojiugo Mbachu 1 , 2 &
Obinna Onwujekwe 1

BMC Health Services Research volume 24 , Article number: 643 ( 2024 ) Cite this article

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School and Community-embedded reproductive health interventions have been implemented in developing countries, with evidence that they led to improved sexual and reproductive health among adolescents. However, this type of intervention is rarely evaluated for its potential adoption and use. This study evaluated the constraints and enablers of the adoption of a school and community-embedded intervention that used community engagement, capacity building, partnerships and collaborations to deliver sexual and reproductive health services to adolescents.

The intervention was implemented between 2019 and 2021 in six local government areas in Ebonyi State. The results on adoption presented here were collected four months into the mid-phase of the project, targeting adolescents, parents, adult family members, healthcare providers, local authorities, and community members. Sixteen in-depth interviews were conducted with policymakers, 14 with health service providers and 18 Focus Group Discussions (FGDs) with parents, community leaders and adolescents who were part of the implementation process. The coding reliability approach, a type of thematic data analysis was used, that involves early theme development and the identification of evidence for the themes.

The adoption of school and community-embedded reproductive health intervention was strong among stakeholders at the early stages of the implementation process. Multi-stakeholder involvement and its multi-component approach made the intervention appealing, thereby enabling its adoption. However, at the later stage, the adoption was constrained by beliefs and norms about sexual and reproductive health (SRH) and the non-incentivisation of stakeholders who acted as advocates at the community level. The sustainability of the intervention may be threatened by the non-incentivisation of stakeholders and the irregular supply of materials and tools to facilitate SRH advocacy at the community level.

Conclusions

The inclusive community-embedded reproductive health intervention was adopted by stakeholders because of the enablers which include timely stakeholder engagement. However, for it to be sustainable, implementers must address the non-incentivising of community-level advocates which serve as constraints.

Peer Review reports

Access to Adolescent Sexual and Reproductive Health (ASRH) services in sub-Saharan African countries is still sub-optimal. This is a public health challenge because of the increased risks of unwanted and unplanned pregnancies, and sexually transmitted infections among others [ 1 , 2 ]. Adolescent sexual and reproductive health interventions have recently gained significant ground as a way to curb this challenge [ 3 ]. They aim to improve the usage of ASRH services thereby enhancing the coping mechanisms of adolescents, prevent unwanted pregnancy and sexually transmitted infections [ 4 ]. Furthermore, they seek to reduce the negative effects of sexual behaviour and enhance the quality of sexual relationships for young people, both now and in the future.

One such intervention used in enhancing ASRH is the Community-Embedded Reproductive Health Care for Adolescents (CERCA) that was developed, implemented and evaluated by Decat and his associates in Latin America cities (Cochabamba in Bolivia, Cuenca in Ecuador, and Managua in Nicaragua) [ 3 , 5 , 6 ]. Consequently, the project combined the creation of an enabling environment, the utilization of media, community engagement, and the involvement of policymakers to enhance adolescent competence in making reproductive health choices, with a particular focus on reducing unplanned pregnancies [ 7 ]. The CERCA project was successful because it sparked conversations about ASRH and responsibilities and encouraged continued community action [ 8 ]. The impact of the CERCA project underscores the need for its implementation in similar settings like Nigeria—a developing country grappling with multifaceted challenges in adolescent sexual and reproductive health.

The effectiveness of ASRH interventions has been proven and their benefits in improving the health and well-being of adolescents cannot be over-emphasised [ 9 ]. However, there still exists some level of apathy towards the implementation and adoption of adolescent sexual and reproductive health interventions despite its presence in the health agenda of several countries [ 4 , 10 ].

Adoption, which is only one type of implementation research outcome, refers to the process of deciding to commit to using an intervention or policy [ 11 ]. Other implementation research outcomes include acceptability, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability [ 12 ]. Adoption can be said to be an intention, initial decision, or action to apply or utilize an innovative and proven practice or intervention [ 12 , 13 ]. We focused on adoption given its significance in the integration and scale-up of interventions. Public health interventions rely not only on their efficacy but also on successful adoption [ 14 ].

Previous studies have highlighted a number of enablers and constraints to the adoption of health interventions, including ASRH interventions [ 11 ]. Some identified enablers of adoption of intervention include stakeholder involvement, and supervision, while constraints include financial constraints, delay in supply of equipment, and shortage of staff [ 9 , 15 ]. Political support, perceived need and benefits of innovation, compatibility, adaptability, availability/quality of resources, availability of financial resources, integration of new programming, shared vision, shared decision making, coordination with other agencies, communication, and supervisory support have also been reported as factors affecting the adoption of interventions [ 11 ]. These studies all have in common the evaluation of barriers and facilitators, but not specific to the adoption of a community-embedded SRH intervention.

Engaging communities is effective in reducing risks to sexual and reproductive health in Nigeria [ 16 ]. However, community support and building the capacity of stakeholders are paramount if interventions will work [ 17 ]. Likewise, there is a call for an innovative approach that institutionalizes sex education in schools and communities [ 18 ]. The adoption of these approaches could help governments and communities become more aware of SRH issues and motivated to work together to improve adolescent health. Therefore, understanding the factors affecting the adoption of community-embedded adolescent sexual and reproductive health intervention is critical in ensuring that intervention leads to integration and possible scale-up to other communities and countries.

While there is evidence that an inclusive community-embedded reproductive health intervention improves access to quality SRH services for adolescents, evidence of the adoption of this approach is scarce [ 3 ]. This study intends to fill the gap by exploring the enablers and constraints to the adoption of an inclusive community-embedded intervention for delivering SRH services to adolescents in Nigeria. Adoption was measured from the perspective of policymakers, providers, community members, and adolescents who participated in the implementation process [ 12 ].

Conceptual framework

For the purpose of this study, we mapped out three key factors to elucidate both constraining factors and enablers influencing adoption: environmental factors, individual factors, and intervention-related factors (Fig. 1 ). These factors were conceptualized based on the ecological framework, which highlights community-level factors, provider characteristics, and intervention attributes. Environmental factors encompass the broader contextual elements surrounding program implementation, such as community dynamics and contextual complexities. Within this domain, certain factors may act as enablers, facilitating adoption, while others may serve as constraints, impeding progress. Similarly, individual factors relate to the personal attributes, beliefs, and behaviors of participants involved in the adoption process. These factors could either foster adoption or present as barriers to implementation. Intervention-related factors encompass the intrinsic characteristics of the program or innovation, outlining its unique features and functionalities. Also, certain intervention factors may enhance adoption, while others may pose challenges. Environmental factors may influence individual factors, which, in turn, may interact with intervention-related factors. Conversely, intervention-related factors could impact both environmental and individual factors. It’s important to note that when these factors serve as constraints, they hinder adoption, whereas when they act as enablers, they promote adoption of intervention [ 19 ].

Conceptual framework showing the factors (enablers and constraints) affecting the adoption of community-embedded ASRH intervention

Study design and area

This study was a qualitative study embedded in a larger intervention study that implemented school and community-based ASRH interventions in communities in Ebonyi State, between 2019 and 2021 [ 20 ]. Ebonyi State is located in the South Eastern region of Nigeria. The state is made up of 13 local government areas (LGAs) divided into three senatorial zones. The state is known for its agricultural activities and is also known to be a source of some solid minerals. Compared to other south-eastern states in Nigeria, Ebonyi has poor ASRH indices – (an unmet need for family planning of 23% and contraceptive prevalence rate of 8.2%) [ 21 ].

Twelve communities were selected from six LGAs (two per LGA) with six [ 6 ] receiving adolescent sexual and reproductive health (ASRH) interventions while the remaining six [ 6 ] served as non-intervention communities. LGAs with high unmet needs, evidenced by unwanted teenage pregnancies and abortions, were prioritized, ensuring a selection that reflects both rural and urban spread [ 22 ]. The intervention lasted for 2 years, it comprised (i) advocacy to stakeholders (ii) training of teachers, peer educators, and health service providers, and (iii) small group awareness campaign sessions.

The researchers adapted the CERCA community-embedded intervention to address the SRH needs of adolescents. The approaches are described below:

Advocacy to stakeholders

Advocacy visits to influential decision-makers in the state were carried out by the researchers, led by OO. This lasted for two consecutive weeks, especially on weekdays. The visit aimed to gain their support for the project and to encourage pro-adolescent SRH decision-making and policy changes at local and state levels. Influential decision-makers were selected based on their position in ministries or agencies that have some impact either directly or indirectly on sexual and reproductive health of adolescents. A letter of introduction was drafted and forwarded to the target agencies, leading to the scheduling of appointments. The targeted agencies for advocacy visits were Ebonyi State Ministry of Health, Ebonyi State Primary Health Care Development Agency, Office of the Sustainable Development Goals, Ebonyi State Ministry of Education, Universal Basic Education Board, Ebonyi State Ministry of Information & Culture, Ebonyi State Broadcasting Corporation, Ebonyi State Ministry of Youth and Sports Development, Agency for Mass Literacy and Non-formal Education. Two legislators – house committee chairmen on health and education were also visited. During each advocacy visit, the advocacy team made a presentation of key findings from the situation analysis on adolescent sexual and reproductive health in Ebonyi state and an appeal for political support in institutionalizing comprehensive sex education for adolescents in secondary schools and non-formal education in selected communities in Ebonyi state.

The community leaders were also visited. The advocacy team leveraged the monthly meeting of the Council of Traditional Rulers (CTR) to present key findings from the situation analysis on sociocultural influences on adolescent SRH and the roles of traditional rulers in addressing sociocultural barriers to accessing SRH information and services for adolescents [ 23 , 24 , 25 ]. Support was also sought from traditional rulers in implementing the intervention. This primarily involved seeking their assistance in community engagement, cultural guidance, and advocacy. Thereafter, the team visited the six study communities and interacted with community leaders (including leaders of women and youth groups, religious leaders and town union executives).

The contacts with stakeholders shaped the development/implementation of the intervention. Some of the stakeholders were included as boundary partners (LGA adolescent focal persons, trained school principals, trained teachers, and peer health educators) in the implementation and subsequently interviewed.

Training of health providers, teachers, and peer educators

A three-day residential training workshop was carried out for senior and mid-level healthcare managers who provide comprehensive and adolescent-friendly SRH services. The participants were drawn from the six LGAs in Ebonyi State. The aim was to build their capacity as providers. Before the training, participants were offered a pre-test to assess their knowledge, followed by another test at the end of the exercise. A total of 29 participants were trained. The training manual used consisted of eight modules: (i) introduction to adolescence and adolescent health; (ii) sexuality and sexual behaviours; (iii) sexually transmitted infections; (iv) principles and practice of counselling; (v) Pregnancy and prevention of pregnancy; (vi) counselling practices on selected health issues of adolescents (including values clarification); (vii) optimal adolescent and youth-friendly services; and (viii) record-keeping and health information systems. The trained providers then stepped down the training to frontline service providers including PHC workers, community health workers and patent medicine vendors through a series of training workshops. In total, 80 voluntary CHWs, and 80 PMVs were trained. More details about the training formats can be found here [ 26 ].

Teachers and peer educators were also trained in the provision of sexual and reproductive health information to adolescents and this lasted for two days. Two workshops (one for teachers and another for peer health educators) were held concurrently. The training manual had eight modules namely: (i) puberty and pubertal changes; (ii) sexual abstinence; (iii) premarital and teenage pregnancy; (iv) human sexual behaviour and sexually transmitted infections; (v) contraception and safe sex; (vi) sex and gender roles, including issues of gender-based violence and sexual abuse; (vii) sources of sexual and reproductive health information and services; and (viii) effective parent-child communication of SRH. Teachers alone also received training on an additional module on principles and practice of counselling. Both teachers and students had a combined session on the last day to learn and discuss the process of establishing school health clubs.

Awareness campaign sessions

A total of five sessions were organised in each implementing LGA with a maximum of 20 persons in each session. A session with parents of adolescents in the community, one session with community leaders (such as religious leaders, traditional leaders, village heads, youth leaders, women leaders, men leaders and leaders of security personnel in the community) and three different sessions with adolescent boys and girls who are either in school or out of school. For parents and community leaders’/influencers’ sessions, information focused on ASRH (Basic information on effective parent-child communication about ASRH matters, basic principles and benefits of good parent-child communication skills, things to avoid and effects of poor parent-child communication on ASRH matters). Other components of the intervention included the distribution of the campaign materials (posters, handbill, face-caps, T-shirts, hand bands etc.) and, pasting of posters (designed specifically for adolescents and parents) in the communities.

Separate sessions were organized for adolescent boys and girls. Trained school teachers, peer educators, and adolescent health focal officers facilitated sessions with adolescents and adults, with technical support provided by the researchers. They were provided with stipends to cover transport fares. Additionally, some young adults who have interest and passion were selected to serve as mentors to adolescents in the community. They were identified through self-expression and active engagement in the activities. Their primary role involves helping them build confidence in making decisions and referring or accompanying them to appropriate healthcare providers. Adolescents engaged in discussions covering various topics, including adolescent sexuality, sexual and reproductive health (SRH) rights, abstinence, contraceptive methods to prevent unintended pregnancies, life skills to prevent sexual violence and exploitation, reporting procedures for sexual assault, accessing SRH information and services, and strategies for preventing and reporting COVID-19 infections.

Study participants and sampling

Four months into the mid-phase of implementing the intervention, a qualitative evaluation was done to assess the adoption. The study participants comprised in-school and out-of-school adolescent boys and girls who are between 13-to-18-years, parents/caregivers of these adolescents, community leaders, teachers, and policymakers. Participants who had some knowledge on topics such as puberty, contraception, sexually transmitted infections (STIs), and the significance of informed decision-making within the realm of adolescent sexual health were purposively selected for the interviews in the schools and communities while policymakers and non-governmental agencies were selected based on their roles and relevance to adolescent sexual and reproductive health. They include State Ministry of Health, State Ministry of Education, State Ministry of Information, State Ministry of Youth and Sports Development, State Ministry of Women Affairs and Social Development, State House of Assembly, State Universal Basic Education Board, State primary health care development agency, civil society organizations, religious and traditional leaders (Table 1 ).

Instrument and data collection methods

The study instruments included pre-tested topic guides for in-depth interviews, (IDI) and focus group discussions (FGD) which were developed by a team of qualitative research experts (Supplementary file 1 ). They were carried out to gain an in-depth understanding of the factors enabling and constraining the adoption of the intervention. The interviews were carried out by experienced researchers in qualitative study in English language. The data collection exercise was led by COM with support from AO and ICA. A total of 18 FGDs and 30 IDIs were conducted, based on the need to attain data saturation. The distribution of the interviews among different groups is shown in the table below.

The objective of the interviews was well explained to the participants before the interviews commenced. All interviews were audio recorded with the permission of participants. Hand-written notes were also taken. At the end of each interview, audio files were well-labelled and saved on a secure computer.

Data analysis

All audio files were transcribed verbatim. Three (AO, ICA and COM) of the researchers were involved in data analysis. Under the guidance of COM, the lead researcher, the team utilized the coding reliability approach, a type of thematic data analysis. The following broad themes were defined as the coding categories: environmental factors, individual factors, and intervention factors. These themes were chosen based on their relevance to the research objectives and the theoretical framework guiding the study. The researchers read through six transcripts and developed a codebook, guided by the research objectives. They were merged and imported into Nvivo tool for qualitative data analysis. Nvivo facilitated the systematic organization, retrieval, and analysis of the coded data. During coding, coders searched for evidence or examples that fit each of the coding categories. The code tree is captured in Fig. 2 .

Findings (table 2 )

Enablers of adoption, environmental factors.

The environmental enablers to the adoption of the intervention include community and background or external factors like existing community health programmes and those spreading them. It also includes peer interaction in the community that improves knowledge and the adoption of the intervention.

Existing community health programmes

The intervention took place in communities where there are existing programmes addressing different health challenges. Stakeholders in health who have also been working in these communities adopted the project from inception because they think that it appeals to them and could help them actualise their objectives in these communities.

Some stakeholders, like the media that are outside the health sector, believe that the intervention aligns with existing media campaigns to promote the health and well-being of adolescents and young people. They remained open to the adoption of the intervention because they also saw the intervention as a novel way of addressing SRH issues. The supporting quote is shown below:

“Well of course as a media person, it has been part of our procedures and advocacy before the program came. That is why I said that immediately we saw you we did not hesitate to embrace you because it is already part of our programme. This is because we believe in the welfare and wellbeing of every segment of the society, especially the young ones” (IDI, Director Media Personnel).

Peer group interaction in the community

The intervention facilitated critical discussions and the exchange of ideas about SRH among peer groups which promoted positive attitudinal change. The positive response observed among the adolescents when their fellow adolescents told them about the benefits of SRH is evidence that peer influence had an impact on the adoption of intervention by adolescents.

Adolescents felt more comfortable when their peers gathered together in groups to talk about SRH matters. Below is a supporting quote:

“Me I will say that it is not difficult because when we are in a group like classmates and we are talking about sex, you know we teenagers, we like to hear such, they will bring their seat to listen to it. It is not difficult. Before you know it, everybody will be like they are talking about sex let’s go and listen to them, before you ‘know it they will form a group and you start telling them” (Female Adolescent in-school, Afikpo South).

Individual factors

Individual factors identified across various stakeholders as enablers of adoption of the SRH interventions include passion, personal interest in SRH and satisfaction, priority setting/proper planning, teaching/leadership position, trust, benefits/popularity gained, and education.

Interests/ passion for SRH

Some of the stakeholders had personal interest in the SRH intervention and volunteered to participate in the intervention without looking forward to monetary gains. The satisfaction and the desire to see things work served as a motivation that enabled the adoption of the intervention. The following quote captures it this way:

“So the point is that I don’t have a single regret, if I ever have a regret it is something just like I said before, I volunteered here, it’s not like I wrote an application and am doing, within the work am doing gives me satisfaction and it’s not about money and let me just say this also, if you talk about money I cannot remember any of your events that you didn’t give money as a matter of fact but I don’t like to quantify my service and my personality cash wise but if you must mention that because the society we work in a lot of people will start with any more money for us but you can see that some of us like I said I am an employer in the NGO” (CSO representative). “I don’t give them any money but I try to carry them along in whatever thing I am doing. In planning, we plan it together and you know this work is what we do with passion and the ones I am working with so far have the same passion” (NGO informant).

Self-actualisation

The intervention brought personal benefits to community advocates, both in skill development or self-actualisation. The training on SRH was noted to have improved the capacity and knowledge of individuals who were already teachers or leaders. The repeated engagements with members of the community increased advocates’ popularity and brought a sense of fulfilment to them. One of the health workers expressed how encouraged and elated she felt when recognised by community members because of the work she does:

“I benefited a lot, it encourages me and boost my moral in doing the work because this work has made many people to know me in our community, it has exposed me, making me to be popular in the community, many women and girls use to come to me asking for certain questions about their sexual lives, they even call me nurse now in my community” (Service provider, Izzi, FGD).

Intervention factors

Factors related to the intervention that are enablers include adaptation of training manual to local context, easy readability and understanding of the manual, stakeholder involvement, multi-level and multidisciplinary nature of the intervention, multi-component nature of the intervention, supervision, availability of materials for field work, knowledge gained and practice of SRH by adolescents, and us of local dialect.

Adaptation of intervention to local context

One of the factors highlighted by the policymakers that made the intervention appealing is that it was adapted to the local context. The intervention and intervention materials were designed to accommodate community peculiarities and include local actors (i.e., religious persons, traditional leaders, parents, community teachers and young adolescents) who are able to drive positive change in young people. Their recognition and inclusion influenced the adoption of the intervention from inception and recorded interesting success.

In addition, training and awareness creation at the community level were carried out using the local dialect of the people. This improved comprehension and understanding of SRH. Using the local dialect also had a way of attracting the attention of the people and making them comfortable. They found it more interesting and felt at home knowing that the person passing the message across is one of their own and not a stranger. For example:

“It is easy because we were taught with our language and we understand it very well. Had it been they used English language to teach, you will understand some but will not understand some, using our dialect made it very easy for us to teach with” (Female Community Leader Agalegu, FGD, 03).

Multistakeholder approach

The intervention considered stakeholder involvement was also pointed out as an enabler to its adoption. Stakeholders at various levels (state, local government, facility, and community level) were involved in the intervention. In addition, stakeholders from different sectors and organisations such as education, media, health, information, women’s affairs, non-governmental organisations, civil society organisations, etc. were involved. One of the stakeholders reported that carrying the government agencies and other sectors along right from the planning phase played an important role in adoption of SRH.

“Ok thank you, let me re-emphasize again that the strategy you adopted because it’s one of your strategies because when you get the stakeholders involved in any activity or program you want to execute, it goes a long way because if the stakeholders are not aware that program is bound to fail” (Director, SMOH).

The multistakeholder approach also employed a multicomponent approach, which implies engaging stakeholders to contribute at different levels. Apart from training of the top stakeholders, individuals were trained at various levels including at the health facilities, schools, and community levels. This approach was noted to be instrumental in the adoption of SRH intervention because it included people working to achieve a common goal. Some supporting quotes include:

“.….I think the strategy is very fine because as I am the x in the state, I can’t be everywhere so if people are trained at each session or each level at the local Government, community level or facility level, they will also be of good use to talk about this adolescent reproductive health [….]so they will also help to train these people, expose them to things that are good. So, training the health workers or volunteers is also very relevant and important (Healthcare executive at SPHCDA).

Furthermore, these various stakeholders were involved in the development of the manual and this made it possible to capture diverse opinions that made adoption easy.

“The way and manner how these manuals were developed; FANTASTIC because I remember that all the major stakeholders were brought, you say your own, this other person say your own and we harmonize. It’s a very good strategy” (Director, at SMOH).

Training inputs

The training improved knowledge and skills to deliver SRH messages to adolescents. As for adolescents, it improved their confidence in discussing the topic with their peers and helped them recognise divergences on SRH issues. Adolescents reported adopting what they learnt and have equally made positive impact in the lives of their friends and siblings:

“What helped me to be able to teach others is that I have put the teachings into practice, that is why I decided to teach my friends and my siblings, I watch them as they put it into practice, and I am very happy that they are doing according to what I taught them” (Female adolescent in Community, Nwofe, FGD, 05).

In addition, materials and tools for fieldwork were given to some service providers, adolescents, teachers, and community leaders who participated in the training. The materials and tools included branded T-shirts, face caps, hand bands, posters, and handbills, designed to promote SRH. They enhanced the adoption of the intervention because it created more awareness and also provided avenues for the topic to be discussed. According to the respondents, the materials were instrumental in raising the topic of SRH for discussion. Some quotes are:

“One of the posters were given to me and I pasted at one chemist shop and I told the owner, if anybody has problem and wants to see the person that pasted this, she should call me and they use to call me after going through it. I posted it there because I know that people always go there to buy medicine. So it is also an avenue to tell people about the services”(Service oprovider, FGD, 06, Izzi).

“I used my own very well, I use to put on my own T-shirt even when I am going to the church and people will be asking me questions about it, I will teach the person there and then. Some people will learn it there on the spot. I also dress on my T-shirt whenever I am going to the office, people ask me questions and I teach them” (Female community leader FGD No 04, Agalegu).

Constraints to the adoption of the intervention

Organisational factors.

Some organizational factors interfered with the decision of health workers to adopt the intervention by health workers. The OICs were expected to collect monthly data about referral cases but they would have to combine this task with other engagements. This affected the understanding of the project’s objectives and the delivery of quality SRH services. They also expressed concern with documenting the cases referred to them. Therefore, the willingness to try these new experiences or consider these new ways of meeting SRH needs of young people may increase workload or interfere with existing projects.

“I mean the health workers, they have a lot to do at this period, so, I cannot say the captured everything they expected them to do, because they are running helter-skelter, doing other partners work, they are too many projects that are going on now (IDI, FP, Female, 53 years-old)”. “It is easier [SRH counselling] but in terms of documentation, there are a lot of tables and calculations in the summary part of it, at times you skip some months without written the summary because there are a lot of registers from other NGOs, kike, NHIS, HIV, GBV, TB is also there, there are a lot of registers to sum at the end of every month, so a times we skip because data collection tools are much with us” (FGD, OICs, Abakaliki).

Secondly, health workers who were part of this research programme and received training were transferred, making it difficult to ascertain their contributions to the project objectives. Some of them even left with the training manuals and other materials provided during the period. For example,

“Those people that were transferred, they are health workers, and another person was transferred and it’s like he left with the manual and another person that took over from her was asking for her won copy of the training manual.’ (IDI, Coordinator of reproductive health, female)”.

Believe and culture about SRH

The intervention took place in areas where culture influences communications about SRH. While the core objective of the project was to suggest and encourage positive behavioural changes among adolescents, some receivers of the intervention do not appeal to this due to deep-rooted beliefs about SRH. This new practice interfered with the belief about SRH issues. It was noted that some adolescents and parents, especially in rural areas, think that SRH communications should be limited to those who are married:

“Some of the challenges, all cultural barriers, that some of our parents and people there in the community, sometimes will stop these children from accessing the services, they will prevent or stop them from coming” (FGD, OIC PHC, Abakaliki).

Additionally, parents who are advocates reported encountering challenges while delivering SRH in religious settings. They reported that discussing SRH among adolescents in churches affected how they were perceived by others and in extreme cases, some of them reported that it affected their businesses. This is because the discussions about sex and sexuality were perceived to be secular and not religious inclined:

“It is difficult in some ways because I teach in the church, it is not easy for someone to come to the church and begin to talk about SRH, people will conclude that you do not have fear or shame to talk about such thing in the church, they will begin to see you as an irresponsible person” (FGD, Female parents, Nwofe). “Yes, I think, like two of them, the one I told you about, the sons of pastor, may be because their religion did not accept what I preach to them, they stopped coming to buy something from me, so I have lost customer from them” (FGD, PMVs, Abakaliki).

Personal life

Adolescents who participated as mentors recounted how difficult it was to keep up with the project because it raises constant scrutiny about their personal lives. It was particularly difficult for those who have been seen in the past engaging in what they are currently teaching. Somehow, this demotivates them from adopting the initiative. For example:

“It is not easy to teach because teaching has affected most of my lifestyle. If someone sees me when I am following a girl, the person will not be willing to listen to me whenever I am talking, they will say “did I not see you with a girl the other day?” It is not easy to teach” (FGD, Adolescent boys, Agalegu).

Certain parents express scepticism regarding the program’s influence on their children. They hold the belief that regardless of the introduced programs, children will follow their own inclinations, deeming any efforts to positively impact their sexual and reproductive health (SRH) as futile and a waste of time.

“One man specifically said that the best thing to do “is to leave them” but I asked to leave your children like that and he said “will I tie them with ropes?” and that is it” (IDI, Vice principal, Ezza South).

Poor delivery of SRH

We gathered that some of the health workers do not adhere to the trainings about how to deliver quality SRH services. It was reported that:

“Health workers approach (in a bad tone and frowned face) it’s another thing all together but now we are dealing with that because it has been scaring, many people run away from going to health facility or even hospitals but I think as primary health care is concerned, we are seriously dealing against it” (IDI, EBSPHCDA, Female).

Intervention-related factors

The ambiguity of manual/tools.

The implementation process made use of training the trainer’s approach, leading to the training of primary health workers, community health workers, and patent medicine vendors. However, some of the focal persons who participated in the training complained that there were technicalities in the delivery that made comprehension difficult. Specifically, the manuals/tools were said to be ambiguous and with small font sizes, making them difficult to understand and discouraging to read.

“That is where the problem lies, it is difficult for us to understand, because the grammar used was very high, some of us didn’t go to school like that, (she laughed) at times, we don’t know where to start, some of us don’t even read it, some of the health workers found it difficult to understand it, next time you make it simpler and more interactive” (IDI, FP, Female, 53 years-old). “The manual was difficult to use especially for some of us that are old because I could not read the characters in the manual. They should endeavour to bolden the characters in the manual in case of next time” (FGD community leaders, male Akalagu).

Shortages of materials

There was quite a number of complains of the shortage of materials and tools. All the advocates reported that the flyers and posters were not enough for them to drop with community members who might be interested in reading more information. The shirts that were distributed at the beginning of the intervention was said to have promoted positive reaction but later, it worn off and was not replaced. This discouraged members from participating in outreach programmes at the later stage of the intervention. See illustrative quotes:

“No, because if there is an arrangement to extend the teaching we don’t have materials to do that, like going to the villages, market square, we don’t have materials for doing that and too amongst the students some of the have overused their T-shirts that write ups are no more showing on the shirts and if you tell to wear it that we are going for evangelism to preach “healthy life” they will their own is dirty and old and the only thing that can attracts audience is something like that” (IDI, Vice Principal, Male, Amuzu).

Referral problem

The implementation process also specified ways through which adolescent SRH needs would be met. Based on this, PMVs and schools were required to refer adolescents with SRH issues to OICs in their communities. The OICs, on their part, were trained to provide expert opinion that addresses adolescents’ SRH concerns. However, one OIC who also double as the focal person of her local government explained that this was not the case as many PMVs did not meet up with this demand. It was reported that the referral process is still problematic.

“The only place that needs to be stressed is the referral process, the PMV dealers, doesn’t refer adolescents with SRH issues to us. Also, the schools that were trained have not been referring students to us. I have never received any referral from PMV” (IDI, FP, Female, ND).

The challenge with the referral process could have been induced by the method used to identify and include PMVs in the trainings. It was gathered that some PMVs who participated in the project do not practice at the intervention sites and as such could not provide the needed services or act within expectations of the project objectives. For illustration:

“Most of these people selected were not in that locality, the place of intervention, do you understand, so, yes, they are working in various places but on the situation whereby no PMVs were selected on the intervention community, it has a big question mark, so, because in Agbaja as a whole, no PMV was selected, even though, Izzi Unuhu, the larger Community, they picked from it but the core intervention area, no PMV was picked, they have 3 CHWs but no PMV’s, so that was an implementation gap” (IDI, FP, Female, 53 years-old).

Lack of stipends

Some health workers, PMVs, parents and teachers were trained to support adolescents who have ASRH issues. These advocates were supported by supervisors who would help them meet the projects objectives and proffer solutions to any challenges. To achieve this, the supervisors may need to frequently visit the communities and the facilities, as the case may be. One problem that was consistent in the data from supervisors is that advocates of ASRH are demotivated due to lack of stipends. This was said to have interfered with their openness to the interventions because they expected to be compensated for their work. For illustration:

“They are complaining of how they work from month to month and they are not being paid, no stipends are giving to them. One of the patent medicine officers is also complaining on the same thing. It’s really difficult for them and this is a program they have gone for and yet nothing has been done” (IDI, FP, Female, 41 years-old).

The requirements for PMVs to provide SRH services within the project’s objectives interfere with their profit orientation. During the training periods, they were constantly drawn to their business that they could hardly immerse themselves in the project. Additionally, they rarely avail themselves to addressing adolescents SRH needs due to the desire to increase sale. For example:

“That is where am worried, it is not enough, PMV’s is business-oriented, they wouldn’t have patient enough to teach those people, because of their time. I think it is appropriate, just that it could not reach all of them, because of time constraints” (IDI, FP, Female, 53 years-old). “Sometimes, especially in the evening, if you have customers that came to buy medicine and there are group of them you are already counselling, there will be saying that am busy discussing with others and I don’t want to attend to them, so, is one of the challenges, and you know I cannot leave my customer and you cannot also allow them to go, because if they go, they may not come back again” (FGD, PMVs, Abakaliki).

Discussions

The study found that stakeholders responded positively to the implementation of community-embedded adolescent health intervention and demonstrated their readiness to adopt the practice. During the project design phase, the researchers held several consultative meetings and co-production workshops to identify and include all stakeholders and get their buy-in and contributions to the project design. The stakeholders’ input led to changes in the original intervention design in ways that met most of their needs. This approach ensures that the inputs of stakeholders reflect the local contexts [ 27 ]. As the findings show, meeting the needs of stakeholders speedily enabled the adoption of the intervention at the earliest phase. This is probably because health policymakers and the media saw it as an avenue to accelerate the state’s agenda on the health and well-being of young people. In a study evaluating the use of result-based financing to improve maternal and neonatal health, it was reported that involving key stakeholders at the earliest phase of intervention promoted adoption and helped in overcoming resistance [ 15 ].

The implementation design also enabled the adoption of the intervention by accommodating community peculiarities. In a study in Zambia, it was found that the success of SRHR interventions rests on their ability to consider community context [ 28 ]. In this study, the implementation design had manuals and tools adapted to local contexts while training and awareness at the community level were carried out in local dialects. Also important at the design stage is the supply of branded t-shirts, face caps, and other materials to community advocates. This raised their commitment even as they utilised the materials as proof of their involvement in larger community development initiatives.

The project was also adopted because it aligned with the stakeholders’ interest in SRH. Those passionate about an improved SRH of young people volunteered and demonstrated ownership at the beginning of the project. This also brought a sense of fulfilment to those already at the forefront of making critical contributions to adolescents’ SRH. Indirectly, it serves as a means of self-actualisation even as stakeholders pursue their interests which also align with the project objectives. As shown in a similar study, stakeholders’ interests may be influenced by the level of power they wield to make changes [ 17 ]. Thus, implementers of ASRH projects may witness early adoption if their project objectives align with powerful stakeholders (these are key players who have substantial impact on decision-making processes as regards SRH at various levels).

On the other hand, the adoption of the intervention was constrained by the demands placed on providers. They experienced heavy workload while combining their tasks with their primary assignments. As a worker in an organisation, it was expected for them to respond to the organisation’s need before meeting the requests of the project. In this study, the supervisors complained that they could not meet their demands from the early stage of the intervention due to primary assignments at the facility level. One study has shown that in regions experiencing human resources crises, combining the project’s task and primary responsibilities may result in an increased workload [ 29 ].

Similarly, adolescents who participated as mentors recounted how difficult it was to keep up with the project because it raises constant scrutiny about their personal lives. This served as a constraint because they were constantly judged in ways that demotivated them. Hence the drop in zeal and motivation to continue to try the initiative.

The interplay among culture, religion and societal norms also contributed as a constraining factor to the adoption of the intervention. The beliefs about SRH created resistance to the positive behavioural changes expected of those who received the intervention. Discussing SRH topics in churches is viewed as a secular activity, rather than religiously inclined. Likewise, parental restrictions and community stigma reinforced the perception that SRH discussions should be limited to only married individuals. In another study, parents only communicate health issues with their children if they perceive that their lives are under immediate threat [ 30 ]. This emphasises the importance of culture and context in the adoption of SRH intervention.

The manuals, tools and materials were not sufficient for use and distribution throughout the implementation. Our findings show that there was low motivation to be part of the outreach because of the lack of materials. These materials are important because they announce the presence of these stakeholders and give them a sense of togetherness. However, when it is not available, stakeholders become demotivated and refuse to participate in awareness campaigns.

Recommendations for future interventions

The prevailing social attitudes and practices at the individual, community, school, and health facility levels often present major barriers to adolescents seeking SRH services. In this study, we have shown that stakeholders can adopt a complex intervention that supports adolescents in ways that enhances communication and strengthen bonds with teachers, healthcare providers, family members and the community. Much like the CERCA project which utilised a community-embedded intervention for reproductive healthcare for adolescent girls, this intervention encouraged and enabled discussions and reflections about SRH services at the community level [ 3 ]. However, implementers may need to up their engagement process to reduce the effect that is due to norms and religious beliefs. Also, interventions may be difficult to adopt when receivers have vested interests that may interfere with the project objectives. Hence the need to design projects with the consideration of stakeholders’ interests. Finally, future studies may want to consider the role of incentives, including monetary, in enabling or constraining the adoption of community-embedded interventions. This is considering the argument that incentives alone cannot guarantee systems adoption [ 31 , 32 ].

Despite these findings, the study has several limitations. First, many types of evaluation outcomes exist but this study narrowed to adoption. While this approach provides valuable insights into the uptake of the intervention, it does not capture the full picture of the intervention’s impact or effectiveness. Future studies may need to explore these, including acceptability and appropriateness from the consumers’ or receivers’ point of view. The study may also benefit from a quantitative assessment of the issue.

There was widespread adoption of the community-embedded reproductive health intervention from early phase of the implementation. At the later phase, however, hesitancy was noted mainly due to the non-incentivisation of community advocates. Getting the right stakeholders to work for the progress of intervention yields many good results. It enables the adoption of the approach especially when stakeholders are engaged appropriately and at the right time.

Data availability

The dataset for the study can be obtained from the corresponding author upon reasonable request.

Abbreviations

Adolescent Sexual and Reproductive Health

Local Government Area

Council of Traditional Rulers

In-depth Interview

Focus Group Discussions

Patent Medicine Vendors

Officer-in-Charge

Ebonyi State Primary Healthcare Development Agency

Community Health Workers

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Acknowledgements

We would like to thank all the stakeholders for health who participated in the study, especially those who facilitated out entry into communities. The research project leading to the results presented in the manuscript received funding from the IDRC MENA + WA implementation research project on maternal and child health (IDRC grant number: 108677). However, the views presented in the manuscript solely belong to the authors and do not necessarily represent the funders.

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Aloysius Odii, Ifeyinwa Chizoba Akamike, Chinyere Ojiugo Mbachu & Obinna Onwujekwe

Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria

Chinyere Ojiugo Mbachu

Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi, Nigeria

Ifeyinwa Chizoba Akamike

Department of Sociology/Anthropology, University of Nigeria, Nsukka, Enugu, Nigeria

Aloysius Odii

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COM and OO conceptualised the study. AO and ICA were responsible for the study design, data collection, data analysis and interpretation, and manuscript writing. COM was responsible for study design, data collection, data analysis and interpretation, and manuscript writing. OO was responsible for study design, reviewing the data analysis, interpretation of the results and writing of this manuscript. All authors read and approved the final manuscript.

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Correspondence to Ifeyinwa Chizoba Akamike .

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Ethical approval was obtained from the Research and Ethics committee of the University of Nigeria Teaching Hospital Enugu (Ref: UNTH/CSA/329/OL.5) and Ebonyi State Ministry of Health (Ref: ERC/SHOH/AI/050/18). All methods were carried out in accordance with relevant guidelines and regulations. A written assent was obtained from adolescents aged 13 to 17 years and older adolescents aged 18 years gave informed consent for the study. Additionally, informed consent was obtained from parents and guardians of adolescents below 18 years’’. This was after being briefed about benefits and risks of participating. Participation was voluntary and confidentiality was maintained.

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Odii, A., Akamike, I.C., Mbachu, C.O. et al. Factors influencing adoption of sexual and reproductive health intervention for adolescents in Ebonyi, Nigeria. BMC Health Serv Res 24 , 643 (2024). https://doi.org/10.1186/s12913-024-11103-y

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Alcohol Health Res World
v.19(3); 1995

Adoption Studies

Researchers use adoption studies to determine the contributions of genetic and environmental factors to the development of alcohol problems. These studies generally compare the outcomes of adoptees who have biological parents with alcohol problems and who grow up in various adoptive environments with the outcomes of adoptees without such family backgrounds but raised in similar environments. Using certain statistical approaches, adoption studies also allow for the evaluation of specific gene-environment interactions in determining an outcome such as alcoholism. To obtain data that allow meaningful and generalizable conclusions, however, scientists must select a representative group of study subjects, obtain valid information about these subjects from a wide variety of sources, and consider biases inherent in adoption practices.

Adoption studies are a powerful tool for evaluating the interactions of genetic and environmental factors in eliciting human characteristics, such as intelligence (i.e., IQ), and disorders, such as alcoholism. The relative importance of “nature” (i.e., genetic inheritance) versus “nurture” (i.e., the rearing environment) in human behavior was first debated at the beginning of this century. Simultaneously, some techniques were developed that are still used to study the inheritance of behaviors, including the family study; the twin study (see the article by Prescott and Kendler, pp. 200–205); and statistical methods, such as regression analysis. One pioneer of human genetics, Sir Francis Galton, used these techniques in his studies. Galton concluded from his investigations that “nature prevails enormously over nurture” ( Pearson 1914–30 ). In 1912, one year after Galton’s death, another researcher, L.F. Richardson, proposed to study children who had been separated from their birth parents in order to investigate the inheritance and development of intelligence ( Richardson 1912–13 ).

Concurrent social changes led to greater public acceptance of adoption and also improved researchers’ access to adoptees. For example, foundling societies and orphanages promoted adopting orphans or children born out of wedlock into foster families who were mostly nonrelatives. Adoptive parents usually received little information about the adoptees’ biological parents. The lack of information may have been attributable to the belief at that time in the environment’s overwhelming importance on a child’s development. In addition, having a child out of wedlock was considered shameful, and consequently, confidentiality protected the birth mother. These “closed” adoptions were advantageous for conducting adoption studies because they clearly separated the biological and environmental influences on the adoptee.

In contrast, during the past two decades, a movement has occurred toward more “open” adoptions, in which biological and adoptive parents receive information about each other. Furthermore, this type of adoption may encourage continuing contact of the birth parents with both the adoptee and the adoptive family. In addition, social changes have drastically reduced the number of infant adoptees. For example, most unwed mothers now keep their children rather than give them up for adoption. These developments have increased the practical problems involved in finding and recruiting suitable adoptees for studies.

Between the 1930’s and 1950’s, most adoption studies examined the heritability and effects of environmental influences on IQ. For example, during the 1930’s, Skodak and Skeels (1949) demonstrated increases in IQ in certain environments using an adoption paradigm. 1 Since the 1960’s, however, adoption studies have been used primarily to demonstrate the importance of genetic factors in psychopathological disorders, such as schizophrenia, alcoholism, or depression (for review, see Cadoret 1986 ). This article briefly examines some of the principles of adoption studies and the considerations required for their effective evaluation.

Influences on Adoptees’ Behavior

The strength of the adoption design—separating genetic from environmental influences on a person’s development—results from removing the child (ideally at birth) from the birth parents and their environment into a different environment with biologically unrelated adoptive parents. Thus, adoption studies assess “real-world” influences on the adoptee’s development while allowing for the separation of genetic and environmental factors that are confounded when children are reared to adulthood by their birth parents.

The adoptee’s development and behavioral outcome result from multiple influences exerted by the birth parents and their environment and by the adoptive parents and their environment (for more information on these influences, see sidebar , p. 199). Determining the contributions of these different influences is a multivariate statistical problem. Several statistical techniques, such as multiple regression analysis and log-linear analysis, can address such problems and have been used in evaluating adoption studies. Bohman, Cloninger, and their research group pioneered the use of multivariate approaches for studying the genetics of alcoholism in their analyses of Swedish adoption data ( Bohman et al. 1982 ; Cloninger et al. 1982 ; Sigvardsson et al. 1982 ). Using these methods, the investigators assessed the contributions of both genetic and environmental factors on the development of alcoholism in the adoptees.

Sources of Influences Affecting Adoptee Outcome

A multitude of influences on the adoptee play a role in determining the adoptee’s development and behavioral outcome. The left side of the diagram (the vertical line represents the separation of biological- and adoptive-family factors) indicates the influences affecting the adoptee during pregnancy, delivery, and the immediate neonatal period, including genetic predispositions inherited from the birth parents (arrow 1) and prenatal and neonatal environmental influences (e.g., maternal alcohol consumption during pregnancy; arrow 3). These genetic and environmental factors also interact with each other, as represented by arrow 5 (e.g., genetically determined antisocial personality disorder or depression in the mother may contribute to her alcohol consumption).

The factors on the right side of the diagram represent the postnatal influences on the adoptee (which, in turn, are influenced by the child) following placement with nonrelatives. Adoptive-parent characteristics are the most important influences affecting the adoptee (arrow 2). The two-headed arrow indicates that the child-parent relationship is an interaction of many factors (e.g., child temperament and parenting skills of adoptive parents). Arrow 4 indicates the correlation between the adoptee and environmental influences. Factors such as friends outside the family influence the adoptee, but the adoptee often simultaneously exerts an influence by seeking out those friends in the first place. Finally, adoptive-parent characteristics and environmental factors also interact with each other (arrow 6). Parent characteristics influence factors such as socioeconomic status. Environmental factors, in turn, can influence parents (e.g., financial stressors may affect parenting behavior by causing depression and irritability).

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Diagram showing sources of factors that affect adoptee outcome.

In addition, adoptees may be matched to a certain extent to prospective parents based on a variety of factors that can lead to correlations between the biological and the adoptive environments (broken arrows). For example, the educational levels of birth parents and adoptive parents could be used as the basis for matching (broken arrow 7). Similarly, a correlation could exist among environmental factors (e.g., both birth parents and adoptive parents live in rural areas; arrow 8).

— Remi J. Cadoret

Selective Placement and Other Confounding Factors

To allow valid conclusions about the relative influences of genes and environment on adoptee outcome, it is essential that factors originating from the birth parents and their environment are unrelated to, and do not interact with, factors originating from the adoptive environment. This condition could be fulfilled by randomly placing infants in adoptive homes. However, adoption usually is not a random process. Adoption agencies carefully screen adoptive parents, and practical placement decisions frequently result in the selection of older, more stable families; families in higher socioeconomic brackets; and intact, rather than single-parent, families. Conversely, families that give up children for adoption commonly are single-parent, low-income ones.

In addition, adoptees may be matched to prospective adoptive parents depending on a variety of factors. For example, at one time adoptees often were matched with adoptive parents based on physical characteristics, such as hair and eye color. Other, more subtle matchings could depend on psychosocial characteristics. For example, an adoption agency might estimate a child’s “potential” from birth-parent characteristics (e.g., education or socioeconomic level) and place the child according to some expectation of future performance. Finally, racial and ethnic origins also could play a role in placement decisions. These practices, referred to as “selective placement,” could confound the normal contributions of biological and environmental factors. This possibility has led to criticism of adoption studies ( Lewontin et al. 1984 ).

Design and Evaluation of Adoption Studies

Adoption studies generally can be classified based on whether the adoptees or the birth parents are the probands (i.e., the initial subjects) of the study ( Rosenthal 1970 ). In the adoptees’ study method, researchers identify proband birth parents with a certain characteristic (e.g., alcoholism) and then examine the outcome of these probands’ adopted-away children. A contrasting design is the adoptees’ family method, in which researchers identify proband adoptees with a certain characteristic (e.g., alcoholism or depression) and subsequently examine both the birth and adoptive parents. Both designs have been used to demonstrate the importance of genetic factors in the development of alcoholism. Whether the adoptees’ study method or the adoptees’ family method is used often depends on certain considerations, such as practicality and the ease of recruiting probands and gathering information about them.

Most adoption studies have used a design comparing high-risk probands (i.e., adoptees or birth parents) having certain characteristics (e.g., alcoholism) with a control group of subjects who lack the pathology of the high-risk group and are considered “normal.” In the adoptees’ study design, researchers usually compare the outcome of adoptees with contrasting biological backgrounds (e.g., alcoholic versus nonalcoholic birth parents); further control can be obtained by matching the proband and control birth parents on variables such as socioeconomic level or age. In the adoptees’ family design, the study compares the biological backgrounds of proband adoptees with those of control adoptees, who usually have been selected for normality. In addition, the adoptees may be matched on variables such as age, gender, and socioeconomic level.

A typical adoptees’ study design compares so-called index adoptees—adult adoptees who have backgrounds of psychopathology (e.g., alcoholism) in their biological families—with age- and sex-matched control adoptees who have no family histories of psychopathology. (For a more detailed description of the design of an adoptees’ study paradigm, see figure 1 .) An adoption study by Cadoret and colleagues (1987) illustrates how the contributions of several genetic and environmental factors to the development of alcoholism can be determined using this method ( figure 2 ). In the study, 160 male adoptees, their biological relatives, and their adoptive families were analyzed regarding alcohol problems, antisocial behavior, and other psychological variables. The study found that a genetic influence, such as alcohol problems in first-degree (i.e., parents) or second-degree (i.e., grandparents) biological relatives, increased an adoptee’s risk for alcohol problems 4.6-fold. Similarly, an environmental influence, such as alcohol problems in a member of the adoptive family, resulted in a 2.7-fold higher risk for alcohol problems in the adoptee, compared with adoptive families without alcohol problems.

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An example of an adoption study using the adoptees’ study method comparing two groups of adoptees: index adoptees and control adoptees.

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Object name is arhw-19-3-195f2.jpg

Results of an adoptees’ study method adoption paradigm based on 160 male adoptees and their biological and adoptive families assessed for alcoholism, antisocial personality disorder, and other psychological parameters. The numbers next to the arrows are odds ratios. 1 (For example, an adoptee with first- or second-degree biological relatives with alcohol problems is 4.6 times more likely to abuse alcohol than an adoptee without such a family background.)

* p < 0.05

** p < 0.01

*** p < 0.001

1 An odds ratio is a measure of association between two variables.

SOURCE: Adapted from Cadoret et al. 1987 .

Because the adoption agencies often were aware of both alcoholism and antisocial behavior in the biological parents, these factors could have influenced placement decisions and correlated with the environmental factor of adoptive family alcohol problems. To control for such potential selective placement effects, the correlations between alcohol problems or antisocial behavior in the biological family and alcohol problems in the adoptive family also were assessed in the statistical analysis ( figure 2 ). The study found no evidence of selective placement based on the factors shown: As indicated by the odds ratios 2 of 1.0, the likelihood of a member of the adoptive family having alcohol problems was the same whether or not biological relatives of the adoptee displayed alcohol problems or antisocial behavior.

Assortative Mating

Another factor that can affect a child’s development and behavior is assortative mating (i.e., the nonrandom choice of a partner based on personal characteristics). For example, an alcoholic person may be more likely than a nonalcoholic person to have an antisocial or alcoholic partner, possibly because of shared traits or behaviors. The combination of two genetic predispositions may enhance the predisposition of the offspring to develop any psychopathology. Multivariate statistical analyses can help control for the effects of assortative mating if relevant information is available on both birth parents. Similar analyses also can be used to control for the genetic predisposition for two disorders (e.g., alcoholism and antisocial personality disorder) within one person.

Alternative Evaluation Methods

Simpler statistical analyses also have been used to evaluate the results of adoption studies. For example, when the assessment of genetic influences is the main objective, a common strategy is to demonstrate that the environmental influences are the same for adoptees from high-risk backgrounds (i.e., with alcoholic biological family members) and low-risk backgrounds (i.e., without alcoholic biological family members). Comparable environmental factors for both groups would indicate that no selective placement occurred that could confound the study results. Using this method, Goodwin and colleagues (1973) demonstrated the importance of a genetic predisposition to the development of alcoholism. However, although environmental influences may be similar when averaged over high- or low-risk adoptee groups, considerable environmental variability still exists among the members of each adoptee group that could affect the outcome of individual adoptees and which should be assessed by multivariate statistical approaches.

Gene-Environment Interactions

In determining the contributions of genetic factors to an outcome such as alcoholism, it is important to know whether a genetic factor exerts its effect only in the presence of a specific environmental condition or does so independently of environment. The adoption paradigm is a powerful tool for evaluating the interaction of specific genetic factors with specific environmental factors that affect adoptee outcome ( DeFries and Plomin 1978 ). For example, researchers and clinicians have long recognized that both conduct disorder and aggressivity predispose an affected person to alcohol and other drug abuse (see figure 2 ). Adoption studies also have demonstrated that antisocial personality disorder in birth parents predisposes adopted-away offspring to both conduct disorder ( Cadoret and Cain 1981 ; Cadoret 1986 ) and aggressivity ( Cadoret et al. 1995 ). In the latter study, however, the genetic predisposition inherited from a birth parent with antisocial personality disorder increased conduct disorder and aggressivity only in adoptees raised in an environment with additional adverse factors (e.g., an adoptive parent suffering from a psychiatric or marital problem) ( figure 3 ) ( Cadoret et al. 1995 ).

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Correlation between antisocial personality disorder in a birth parent, adverse environmental factors in the adoptive home (i.e., marital, legal, psychiatric, or substance abuse problems in the adoptive parents), and adolescent aggressivity in the adoptee. If a birth parent has an antisocial personality, a positive correlation exists between adverse environmental factors and aggressivity symptoms in the adoptee. This correlation is significantly different when none of the birth parents has an antisocial personality.

SOURCE: Adapted from Cadoret et al. 1995 .

Findings from the study of this type of gene-environment interaction may suggest points of intervention, thereby helping to prevent behavior leading to alcoholism. For instance, in the above example, modifications of the environment (e.g., treatment of the adoptive parents’ problems) could affect the adoptee’s outcome even in the presence of a genetic predisposition.

Factors Influencing Study Quality

Obtaining valid information.

Valid information about the birth parents, the adoptive parents, and the rearing environment is crucial when using adoption studies to assess the influences of genetic and environmental factors on behavior. This information must address the four important sources of influences on the adoptee: the genetic and environmental factors from the birth parents, the parental influences from the adoptive parents, and the adoptive family environment. Thus, a major technical difficulty in adoption studies is arranging for data collection from a wide range of sources, some of which are protected by confidentiality.

Information about the birth parents and their behaviors is necessary to determine which adoptee characteristics may represent phenotypes of a genetic predisposition inherited from the parents (e.g., genes predisposing the adoptee to develop alcoholism). This information can be obtained from the records of the adoption agency, hospitals, social services, and similar sources. In studies of adoptees born out of wedlock, reliable information about birth fathers frequently is lacking. However, recent laws requiring written permission from biological fathers to release children for adoption may improve information collection. For example, if a birth father’s name is available, archival information from hospitalizations, incarcerations, or other records (e.g., death certificates) can be obtained provided that the confidentiality required for such records can be maintained.

Adoption agencies usually can provide information about pregnancy and delivery (i.e., influences of the birth-parent environment). Similarly, agency records can supply a large amount of personal information about the adoptive parents and the rearing environment. This information is especially of interest because adoption studies can measure the influences of specific environmental effects as effectively as the influences of genetic effects. Information about the adoptees themselves also is readily available in most cases.

Ideally, adoption studies would include information obtained by personal interviews with all the people who primarily affect the adoptee’s outcome (i.e., the birth parents, the adoptive parents, the adoptee, and friends of the adoptee). Data collected solely from institutional records, however, such as those from the central registries in Scandinavian countries, also can provide valuable information and, at the very least, be used to identify subjects for direct study. Long-term followup of the adoptees, their birth parents, and their adoptive families would result in even more valid information about behaviors that tend to change over time, such as conduct disorders, alcohol abuse, or depression. Such longitudinal studies could considerably increase the identification of psychopathological behaviors that might go undetected in a study relying only on information gathered during one time period.

Proband Recruitment

How the probands are recruited also can affect the quality of a study’s conclusions. One potential source of bias is the influence of environmental factors on the selection of proband adoptees in the adoptees’ family method. For example, psychological or social problems in an adoptive family may contribute to the adoptee’s psychopathology. Simultaneously, these problems may prompt the family and the adoptee to seek more treatment and thus increase their chances of being included in a sample of adoptees recruited from a clinic population. Factors such as these may compromise the representativeness of the sample.

Similarly, refusal rates among potential study participants could influence the quality of the data obtained. For example, it is possible that adoptees and their families who refuse to participate in a study as a group are distinguished by certain qualities (e.g., personality characteristics). Consequently, their refusal could reduce the representativeness of the study sample.

Generalizability of Adoption Studies

Whether the findings from adoption studies can be used to draw general conclusions about the contribution of both genetic and environmental factors to the development of alcoholism depends largely on how representative the adoptee sample is. Representativeness, in turn, is determined by variables, such as the criteria for proband selection. Although many of these variables can be controlled for or at least recognized, the inherent biases in adoption practices (e.g., selective placement and predominant recruitment of adoptive families from certain population groups) limit generalizability.

Despite the existing limitations and the technical problems associated with conducting adoption studies, the adoption paradigm provides important information about the significance of specific genetic and environmental factors in human behavior. In addition, adoption studies allow researchers to identify specific genetic-environmental interactions that could be relevant for designing early interventions for behaviors that predispose a person to alcohol abuse and dependence.

1 For a definition of this and other technical terms used in this article, see central glossary, pp. 182–183.

2 An odds ratio is a measure of association between two variables.

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Internet use statistically associated with higher wellbeing, finds new global Oxford study

Links between internet adoption and wellbeing are likely to be positive, despite popular concerns to the contrary, according to a major new international study from researchers at the Oxford Internet Institute, part of the University of Oxford.

The study encompassed more than two million participants psychological wellbeing from 2006-2021 across 168 countries, in relation to internet use and psychological well-being across 33,792 different statistical models and subsets of data, 84.9% of associations between internet connectivity and wellbeing were positive and statistically significant.

The study analysed data from two million individuals aged 15 to 99 in 168 countries, including Latin America, Asia, and Africa and found internet access and use was consistently associated with positive wellbeing.

Assistant Professor Matti Vuorre, Tilburg University and Research Associate, Oxford Internet Institute and Professor Andrew Przybylski, Oxford Internet Institute carried out the study to assess how technology relates to wellbeing in parts of the world that are rarely studied.

Professor Przybylski said: 'Whilst internet technologies and platforms and their potential psychological consequences remain debated, research to date has been inconclusive and of limited geographic and demographic scope. The overwhelming majority of studies have focused on the Global North and younger people thereby ignoring the fact that the penetration of the internet has been, and continues to be, a global phenomenon'.

'We set out to address this gap by analysing how internet access, mobile internet access and active internet use might predict psychological wellbeing on a global level across the life stages. To our knowledge, no other research has directly grappled with these issues and addressed the worldwide scope of the debate.'

The researchers studied eight indicators of well-being: life satisfaction, daily negative and positive experiences, two indices of social well-being, physical wellbeing, community wellbeing and experiences of purpose.

Commenting on the findings, Professor Vuorre said, “We were surprised to find a positive correlation between well-being and internet use across the majority of the thousands of models we used for our analysis.”

Whilst the associations between internet access and use for the average country was very consistently positive, the researchers did find some variation by gender and wellbeing indicators: The researchers found that 4.9% of associations linking internet use and community well-being were negative, with most of those observed among young women aged 15-24yrs.

Whilst not identified by the researchers as a causal relation, the paper notes that this specific finding is consistent with previous reports of increased cyberbullying and more negative associations between social media use and depressive symptoms among young women.

Adds Przybylski, 'Overall we found that average associations were consistent across internet adoption predictors and wellbeing outcomes, with those who had access to or actively used the internet reporting meaningfully greater wellbeing than those who did not'.

'We hope our findings bring some greater context to the screentime debate however further work is still needed in this important area. We urge platform providers to share their detailed data on user behaviour with social scientists working in this field for transparent and independent scientific enquiry, to enable a more comprehensive understanding of internet technologies in our daily lives.'

In the study, the researchers examined data from the Gallup World Poll, from 2,414,294 individuals from 168 countries, from 2006-2021. The poll assessed well-being with face-to-face and phone surveys by local interviewers in the respondents’ native languages. The researchers applied statistical modelling techniques to the data using wellbeing indicators to test the association between internet adoption and wellbeing outcomes.

Watch the American Psychological Association (APA) video highlighting the key findings from the research.

Download the paper ‘ A multiverse analysis of the associations between internet use and well-being ’ published in the journal Technology, Mind and Behaviour, American Psychological Association.

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TCS AI for Business Study – Key Findings

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Reimagining business with AI

Artificial intelligence (AI) offers new opportunities to radically reinvent the way we do business. This study explores how CEOs and top decision makers around the world are responding to the transformative potential of AI, and:

Managing their AI strategy

Making their organization AI-ready

Evaluating the potential value of AI for their business

Balancing opportunity with risk

Download the full report

The transformative power of AI

Most executives surveyed have a positive sentiment toward AI.

54% believe its impact will be greater than or equal to the internet.

59% believe AI’s impact will be greater than or equal to that of smartphones.

57% are excited or optimistic about AI’s potential impact on their business.

Nearly three-quarters of them also recognize the need to make changes to take full advantage of AI.

72% are currently reworking or planning to rework their business strategy or operations.

Yet there’s no consensus on AI adoption strategies and not enough metrics to measure success.

72% say they need better KPIs for their AI implementations.

A graphic showing that 57% of the executives surveyed are excited about AI and 72% expect to make changes in response to it

Sentiment around AI

Corporate leaders are optimistic about AI

Current state of AI

59% of corporate functions have AI implementations in-process or have completed AI projects.

34% of corporate functions are planning AI implementations.

Only 20% of corporate leaders say they are well-positioned to leverage AI to their strategic advantage.

The top three challenges according to the executives in the survey

Surveyed executives identify their main challenges

Infrastructure, customer expectations and IT support are concerns

Challenges for GenAI

The advent of Generative AI has brought strategic challenges to the forefront.

Security and privacy

Ethical and responsible AI use

Lack of IT readiness 

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Not enough metrics for ROI

As the integration of AI into business processes accelerates, expected financial return on such an investment becomes increasingly significant. But only 19% of the respondents said they have "good enough" metrics and KPIs for their current stage of AI deployments. Without adequate KPIs for AI-enabled operations, proving ROI and getting future buy-in is challenging.

Quick takeaways

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Future of AI

Most executives believe AI will augment and enhance human capabilities, enabling people to focus on higher-value activities that require creativity, empathy, and strategic thinking.

65% of companies think human strategic decision-making and creativity will remain essential to their competitive advantage.

As AI becomes more advanced and part of “business as usual,” the role of humans in the workplace will evolve. 41% of companies expect most of their employees will be using GenAI on a daily basis in three years.

Innovation and revenue growth will be a focus for future AI implementations. 69% of companies are more focused on using AI to spur innovation and increase revenue than on lowering costs and optimizing operations.

GenAI Implementations

Tcs recommendations.

Focus on the value, not the technology

Embrace AI initiatives that support organizational priorities and use cases with the potential to enhance value chains and drive business outcomes like revenue growth, cost savings, and improved customer experience.

Adopt a more strategic approach

Create a multidimensional approach to AI adoption that encompasses strategic goals beyond productivity and revenue growth to include quality, reducing risk, improving operational efficiencies and organizational decision making.

Make the business and culture AI-ready

Invest not only in the necessary technology and infrastructure, but also on a culture that embraces change, experimentation, and continuous learning.

Create higher-level relationships with customers

Capitalize on AI’s capabilities to deliver more personalized, proactive and valuable experiences across the customer journey and differentiate your business from the competition.

Plan for success, not scarcity

Be ready for AI to expand revenue, opportunity and innovation and create new ways for humans to do their current jobs or even create new roles.

About the study

TCS’ Thought Leadership Institute conducted a double-blinded study of approximately 1,272 senior executives with P&L responsibilities in 12 industry sectors across Asia, Europe, Nordics, LATAM, North America and the United Kingdom/Ireland, with respondents having annual revenue of $5 billion to $100 billion.
This global study examines how CEOs, LOBs, directors/business line managers are preparing their business how to be AI-ready, including their strategy around operations, talent and future implementation plans, and provides best practice recommendations based on these insights.

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From start-up to scale-up: Accelerating growth in construction technology

Construction sites in 2023 might in many ways resemble those in 1923, with manual bricklaying, paper blueprints, and scaffold towers. At $12 trillion, 1 Oxford Economics, March 2023. architecture, engineering, and construction (AEC) is one of the biggest industries in the world, but historically it has been among the slowest to digitize and innovate.

This, however, is changing fast: strong demand for infrastructure, a shortage of skilled labor, and increased stakeholder pressure for data transparency and integration are all accelerating digital adoption. As a result, the AEC tech ecosystem has experienced an explosion of investment and a wave of start-up launches. An estimated $50 billion was invested in AEC tech between 2020 to 2022, 85 percent higher than the previous three years. During the same period, the number of deals in the industry increased 30 percent to 1,229 (Exhibit 1).

Although the AEC tech industry is maturing, it is not yet at the scale and sophistication of more established software markets like logistics, manufacturing, and agriculture. The industry boasts fewer scale-ups and unicorns relative to its size. And it is hard for AEC tech companies to grow efficiently due to several dynamics among AEC customers, including fragmentation, low IT spend (relative to other industries), and entrenched analog ways of working.

In this environment, how can AEC tech companies accelerate adoption and sales and achieve scale? To answer this question, we surveyed approximately 100 investors and AEC tech players in 2022 and interviewed founders, investors, and large software companies in the industry. Using primary research and publicly available data, we also mapped and analyzed more than 3,000 AEC tech companies. 2 PitchBook, November 15, 2022. In this article, we review the findings of that research. We outline the investment trends that are accelerating the digitization of the industry, and we suggest how tech businesses, and their investors, can address challenges to get on a path of efficient growth.

Trends accelerating the digitization of aec, hurdles to scale aec tech investments remain, strategies for scaling aec tech businesses.

Digitization of the AEC industry started gathering steam a decade ago, but the pace has accelerated over the past three years—and a number of trends suggest it will continue to do so (see sidebar, “What do we mean by architecture, engineering, and construction tech?”).

Economic factors and regulation are prompting investment

What do we mean by architecture, engineering, and construction tech.

A variety of software and tech is used across the architecture, engineering, and construction (AEC) industry. It includes design software, robotics, and tools for the planning, scheduling, budgeting, and performance management of projects (exhibit). Companies in the AEC tech industry range from multibillion-dollar software giants to one-person start-ups.

A combination of supply-and-demand factors are prompting investment in AEC tech. On one hand, global demand for long-term construction is strong, in part because of increased stimulus by governments, such as the $1.2 trillion Bipartisan Infrastructure Law in the United States and the €800 billion NextGenerationEU fund in Europe. More asset owners are also investing sizeable capital to decarbonize their portfolios to make them climate resilient. On the other hand, there is a shortage of skilled workers as more retire or transition to other industries. The United States has 440,000 vacancies in AEC, compared with around 300,000 in 2019, whereas the United Kingdom’s vacancies have nearly doubled since 2019. 3 “Construction: NAICS 23,” US Bureau of Labor Statistics, 2023; “UK job vacancies (thousand): Construction,” UK Office for National Statistics, March 2023. The industry is deploying digital technology to help increase productivity and bridge this gap between supply and demand.

Meanwhile, regulatory changes aimed at creating a more connected industry are reinforcing this wave of digitization. For example, the United Kingdom’s Building Safety Act requires a digital ledger of all building data for new residential buildings, and Sweden’s ID06 requires digital records of all the construction workers on a construction site.

Investor optimism is high

Investment in AEC tech has grown multifold and, based on our research, more and more investors are recognizing AEC tech’s potential to fundamentally change the structure of the construction industry and redistribute value pools at scale. This momentum is likely to continue. Seventy-seven percent of the respondents to our survey expect to invest in AEC tech at similar or higher levels in 2023, and 64 percent see it generating higher returns versus other verticals.

Seventy-seven percent of the respondents to our survey expect to invest in AEC tech at similar or higher levels in 2023.

The tech scene is maturing

The proportion of late-stage venture capital in total AEC tech investment totaled $11.5 billion between 2020 and 2022, more than triple that of the previous three years (Exhibit 2). Meanwhile, M&A continues to be the largest source of funding for AEC tech ventures, accounting for 48 percent of all investments and 68 percent of all exits. The growth of the industry is further reflected in the fact that the median deal size and post-money valuation 4 Post-money valuation is a measure of a company’s valuation that includes all external investments. in the industry has more than doubled since 2017 (Exhibit 3).

Companies and customers are still seeking interoperability

In 2020, we observed that AEC tech players were targeting multiple use cases to address customer pain points. 5 “ Rise of the platform era: The next chapter in construction technology ,” McKinsey, October 30, 2020. This trend has continued, led by customer demand for interoperability—either through virtual platforms built using open standards and workflows, such as openBIM, or with one-stop-shop platforms such as those developed by some of the largest AEC tech companies. Indeed, nearly half of the companies we analyzed offer customers solutions that address three or more use cases.

AEC technology and property technology are converging

Until now, AEC tech and property technology (proptech) have evolved as separate ecosystems. AEC tech has focused on the design and construction of assets, while proptech has focused on the financing, planning, operation, and maintenance aspects of assets. This is starting to change, as customers and technology players see value in connecting the two. Our analysis shows that 20 percent of AEC tech companies also address at least one proptech use case: for example, linking the design and operation of building management systems using a digital twin.

While the trends above have helped expand the ecosystem of AEC-focused tech businesses and start-ups, investors and founders still wonder how best to pursue efficient growth—defined as the ability to grow annual recurring revenues (ARR) and to generate free cash flow (FCF) from those revenues. 6 Annual recurring revenue is the revenue that a company (often businesses that operate on a subscription-based model) expects to receive from customers on an annual basis. Free cash flow is the cash generated by a company after paying operating expenses and capital expenditures. Our analysis across industries shows that as software companies expand, efficient growth increasingly correlates strongly with valuations (Exhibit 4).

Within the AEC technology industry, however, our research also indicates that efficient growth is particularly tough to achieve for four reasons:

Customer fragmentation. The average construction company employs fewer than ten people. The average project involves more than 100 different suppliers and subcontractors. So achieving scale requires selling to a large number of companies. This means that sales growth can be labor intensive and slow. As one investor noted, “This is a risk-averse and fragmented sector at its core, so growth is slow, but it is extremely sticky.”
Multiple customer personas. Founders frequently tell us that identifying the real customer is tough because they lack a clear understanding of user versus buyer personas. Depending on the project, for example, the customer could be the project manager, IT manager, or procurement manager. And often, purchase decisions are made at the project level, not the enterprise level. As a result, companies need to resell the product again to the next project, which drives down net retention and raises acquisition costs. As one investor said, “The most successful companies have a plan to sell to the enterprise, not just the project.”
Low margins and economic headwinds. Making the case for spending on software can be tough for AEC companies when there is limited capacity for investment. The industry has low margins and increasing economic headwinds, including materials cost inflation. Moreover, the typical IT spend for AEC companies is 1 to 2 percent of the revenue, compared with the 3 to 5 percent average across industries. 7 “Gartner top strategic technology trends for 2022,” Gartner, October 2021. Against this backdrop, solutions must come with a business case. Although ROI can be high, until recently players have not been effective at quantifying benefits. As one investor said, “In a low-margin industry, and in this market environment in particular, it is important that companies can clearly demonstrate and measure the cost-saving benefits of their product.”
Adoption and scaling challenges. Driving tech adoption in a projects business like construction poses several challenges: users often switch products among different projects—sometimes they need to adopt different tools depending on client preferences, and staff come and go. Furthermore, the industry has traditionally had limited digital capabilities, although this is changing as workers become accustomed to using digital technology in their everyday lives. And as one AEC company executive said, “The pandemic forced us to accelerate adoption from the office to the site overnight.”

For companies that can overcome these barriers, there is a big prize up for grabs: a customer base that is larger than most other industries. So what does it take? Our analysis of tech companies in AEC, as well as other industries like manufacturing, travel, and logistics, shows five common growth characteristics.

Pursue a big total addressable market and a bold vision

As one investor told us, “If the extent of your vision is to sell tools to solve a niche problem, then we’re not excited. We are looking for founders with vision and mission to improve outcomes for big swathes of the market.” Having a bold vision—and being able to effectively articulate how it benefits the user and the broader industry—helps attract talent, investors, and customers, and allows companies to move faster as they continually course-correct toward a North Star. For example, one AEC tech company focuses on improving predictability of project outcomes and uses that simple vision to expand the total addressable market (TAM) beyond contractors and planners to cover a far broader customer set, including project owners, banks, and insurance companies.

A bold vision usually means founders are thinking about the entire AEC tech ecosystem and figuring out ways in which their company can work with other providers to create a seamless user experience and unlock newfound value for a broader set of customers. For example, one AEC design platform expanded its core offering beyond architects and engineers to connect to product suppliers, and thus monetize transactions for building products used in designs.

Achieve a great product market fit

Finding the right product market fit is a key part of the investment decision-making process for investors in most industries, but AEC tech companies often do not get it right. In fact, as our survey indicates, the most common issues observed by AEC tech investors are an overfocus on engineering (rather than product and market fit) and product fragmentation (Exhibit 5).

As one AEC tech player noted, “Niche, technical design tools are often built by self-taught developers and construction professionals who built the tool to solve a specific problem or fill a gap in their workflow. As such, the very nature of those tools focuses on the tech and not the user experience.” In our discussions with start-ups and investors, three common themes emerged that can help create a better product market fit. All three elements require strong product management capabilities .

First is focus. Since customer needs differ across segments, companies would do well to focus on one or a few specific segments, whether they are targeting architects or subcontractors or distributors. As one founder put it, “I have potential customers in manufacturing, retail, construction, and facilities management across more than ten geographies, but we have to focus, or we will achieve nothing.”

Second is feedback. As one investor told us, “Many contech [construction technology] firms are founded by industry professionals who launched their business to solve a problem, so they have huge product focus. We need to see more founders with a balanced product and market/customer focus.” One way to sharpen market focus is to build a network of customers and collaborators. Most successful players do this through their investors’ networks and beta customers, who benefit from low-cost early releases in return for investment in testing and development feedback. And a side benefit is that they can provide access to a critical mass of other customers (Exhibit 6).

Third is flexibility. Nearly every start-up and scale-up we have spoken to has seen a big shift in their product proposition because they responded to market views and kept evolving to optimize the product market fit. For example, one start-up developed an app to measure material waste from construction sites but eventually evolved it to measure embodied carbon in materials.

Build a customer acquisition engine with a scalable revenue and distribution model

Valuations for start-ups are tied strongly with the ARR growth metric. In a fragmented market like AEC, customer acquisition is difficult and expensive. Based on our research, leading players differentiate themselves with three moves to maximize the ARR bang for each buck spent on marketing and R&D:

Deliver a scalable revenue model. As one investor said, “Some products require so much customization that the software company becomes a consultancy.” Successful businesses have a product that can be deployed with minimal customization and training (and that usually means software rather than hardware). And where customization or training is required, they invest time only in high-potential customers and often partner with independent software vendors to deliver at scale.
Find creative routes to market. You’re never going to crack the market one customer at a time. Successful players use their investors and existing customers to open new routes to market. They also lock in users early. For example, one design software player gave away free copies of its software to architecture students, who then took it to their new employers. Moreover, these players have a channel strategy aligned with customer tiers, and that includes not only value-added resellers (VARs) and distributors but also low-cost remote channels (including multilingual remote inside-sales centers) and self-serve, web shop, and e-commerce.
Supercharge the sales team. Successful software companies incentivize their direct-sales teams to cross-sell and upsell and drive key account management capabilities. One leading player with multiple brands centralized its go to market across brands to accelerate cross-sell and upsell and capped bonuses on some established products to incentivize sales of new products. The best sales organizations are underpinned by data that allows them to see the relationship between specific, often siloed, sales and marketing activities and overall growth outcomes.

Improve net retention with customer success

Our analysis shows that as software companies grow, the most important driver of valuation shifts from pure growth, often measured by ARR, to include the ability to generate FCF from ARR. In short, it’s not enough to just have customers; you need to earn money from them. In what is commonly referred to as the “rule of 40,” the sum of percentage growth and the FCF rate should equal 40 percent or higher. 8 Paul Roche and Sid Tandon, “ SaaS and the Rule of 40: Keys to the critical value creation metric ,” McKinsey, August 3, 2021.

Achieving strong FCF is in large part about optimizing the payback period—that is, how long does it take to recover your customer acquisition costs. This means acquiring new customers efficiently, retaining customers, and upselling and cross-selling to them. This is measured by net retention rate (NRR), 9 Net retention rate is a metric that shows how effective a company is at driving growth in its existing customer base while keeping the churn low. which requires a laser focus on customer success. Across sectors, companies with high NRRs demonstrate three common characteristics:

They know their numbers. At the heart of customer success is a data-driven understanding of how customers obtain value from a specific product. Maximizing NRR is a game of inches, so leaders analyze the many drivers of growth and churn (upsell, contract cancellation, additional licenses, and so on) at a customer level and respond with targeted interventions (for example, offering bundles for additional “seats” as usage reaches contract limits).
They set up a dedicated customer success function. A team that can work with customers to get maximum value from the product is particularly important in AEC, where customers are less digitally mature and solutions are less well established. For example, the largest AEC technology companies have customer success teams and run conferences and training for their users. One software company hired a retired construction contractor for its customer success function to better understand customer needs.
They deliver customer success at low cost. Customer success does not have to mean dedicated (and expensive) customer support. It can often be delivered at lower cost by cultivating user communities and promoting the use of online tutorials, for example. One AEC tech company gained thousands of users on zero-marketing spend by leveraging its community forums and industry networks—effectively putting its own customers to work.

Build functional maturity as you scale

As software companies grow beyond the start-up and scale-up stages, growth rates slow, and FCF (and hence, valuation) is increasingly driven by operational efficiency. This typically comes down to optimizing NRR as well as marketing and sales spend (which can be 50 percent or more of the revenues of typical software companies). At-scale software companies in the top quartile for valuation typically exhibit the following characteristics 10 “SaaS and the Rule of 40,” 2021. :

As software companies grow beyond the start-up and scale-up stages, growth rates slow, and free cash flow (and hence, valuation) is increasingly driven by operational efficiency.

Optimize marketing and sales spend. Leading software players allocate marketing and sales spend against future, not past, revenue opportunities to give high-growth accounts the biggest coverage. They also continuously segment customers, targeting lower-potential customers through web sales/e-commerce and inside sales while increasing spend on the highest-potential customers.
Continuously optimize pricing and track impact. Leading players build customer business cases to link pricing to the value generated for customers. They also track the impact of pricing changes in near real time and optimize accordingly. Companies would also do well to make sure their payment terms are right. As one investor explained, AEC tech players often price based on a project or milestone. “This is not ARR, even though some may call it that. And because construction is often subject to delays, this means the risk attached to these revenue streams is very high, which puts off potential investors.”
Lean on data and automate processes. Successful software companies leverage data, AI, and automated processes across the business in a variety of ways, including identifying leads and proactively targeting cross-sell and upsell opportunities, leveraging usage information in pricing and product decisions, and assessing developer velocity .
Strengthen the business-building muscle. Tech companies of every size often reach the tip of a growth curve without a market-ready venture or offering that can pick up the slack, so their growth dips. Leading players maintain momentum by launching net-new businesses more quickly. They incubate new businesses thoughtfully, with dedicated resourcing for product development and go to market.

Several tailwinds are powering growth in the AEC tech industry despite the near-term challenges of the economic slowdown. To capitalize on the investment opportunities and achieve efficient growth, investors and tech companies can learn from the most successful AEC tech companies and catch the wave in this exciting industry.

The authors wish to thank Daniele Di Mattia, Julien Gagnon, Josh Johnson, and Adam Singer for their contributions to this article.

This article was edited by Arshiya Khullar, an editor in the Gurugram office.

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Increased Risk of Pedestrian Accidents with Electric and Hybrid Vehicles: A UK Study Reveals

A ccording to recent research, pedestrians are at a greater risk of being struck by electric or hybrid cars than those powered by petrol or diesel. The study, which underwent peer review and was published in the Journal of Epidemiology and Community Health, examined road casualty statistics within the UK from 2013 to 2017.

Findings from the study have shown that the likelihood of electric and hybrid vehicles being involved in pedestrian accidents is twice that of petrol or diesel vehicles. The incidence rate is even higher in urban areas, being threefold more probable compared to rural regions.

Looking into 916,713 recorded incidents that involved pedestrian injuries, it was found that the average yearly pedestrian casualty rate per 100 million vehicle miles traveled was 5.16 for electric and hybrid vehicles, as opposed to 2.40 for petrol and diesel vehicles. These findings covered 32 billion miles of electric/hybrid vehicle travel and 3 trillion miles of petrol/diesel vehicle travel.

The study emphasized the impact of road injuries on mortality rates, being the most common cause of deaths among children and young people. It also pointed out that pedestrians make up one quarter of all road fatalities.

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The researchers attributed the heightened risk specifically to the relative silence of electric and hybrid vehicles, which can be significantly harder to hear for pedestrians, especially in noisy urban settings. Additionally, they noted the potential correlation between inexperienced younger drivers being both more prone to accidents and more likely to drive an electric vehicle.

The study summarized that while more people are injured by petrol and diesel cars, electric cars represent a higher risk to pedestrians, with urban environments showing a higher incidence rate.

Despite the findings, the study authors advocated for continued support of walking and cycling for their health benefits, highlighting the need to understand and mitigate any increased risks linked to traffic injury.

In light of the growing push to transition away from petrol and diesel cars , the research calls for measures to address the increased safety risks posed by electric and hybrid vehicles. While acknowledging limitations such as a lack of data post-2017 due to technical issues with the National Travel Survey (NTS), the study’s conclusions are aimed at informing policy for improved pedestrian safety. The Department for Transport has been approached by Sky News for their input on this issue.

FAQs about Electric Vehicle Pedestrian Safety

Electric and hybrid vehicles are generally quieter than petrol or diesel cars, making them harder for pedestrians to hear, especially in busy urban areas.

The study found that pedestrian accidents involving electric and hybrid vehicles are three times more likely to occur in urban areas than in rural ones.

The pedestrian casualty rate per 100 million miles traveled is 5.16 for electric/hybrid vehicles compared to 2.40 for petrol and diesel vehicles.

Yes, the researchers advocate for walking and cycling due to their health benefits, while emphasizing the importance of mitigating traffic injury risks.

Sky News has reached out to the Department for Transport for their comments but has not yet received a response.

The recent study published in the Journal of Epidemiology and Community Health has raised significant concerns regarding pedestrian safety in relation to electric and hybrid vehicles. The research clearly indicates that these vehicles pose a greater risk to pedestrians compared to traditional petrol and diesel cars, particularly in urban areas. While the study should not dissuade the public from engaging in active transportation, such as walking and cycling, it does underscore the need for greater awareness and preventive measures to protect pedestrians as societies move towards cleaner transportation technologies. Future policy-making and vehicle design must account for these findings to ensure the transition to electric vehicles does not come at the cost of public safety.

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Factors influencing adoption of sexual and reproductive health intervention for adolescents in Ebonyi, Nigeria

Conclusions

Conceptual framework

Study design and area

Advocacy to stakeholders

Training of health providers, teachers, and peer educators

Awareness campaign sessions

Study participants and sampling

Instrument and data collection methods

Data analysis

Findings (table 2 )

Existing community health programmes

Peer group interaction in the community

Individual factors

Interests/ passion for SRH

Self-actualisation

Intervention factors

Adaptation of intervention to local context

Multistakeholder approach

Training inputs

Constraints to the adoption of the intervention

Believe and culture about SRH

Personal life

Poor delivery of SRH

Intervention-related factors

Shortages of materials

Referral problem

Lack of stipends

Discussions

Recommendations for future interventions

Data availability

Abbreviations

Acknowledgements

Author information

Contributions