Non-adult child supervision practices in Lao People’s Democratic Republic

Child Abuse & Neglect 84 (2018) 217–228

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Non-adult child supervision practices in Lao People’s Democratic Republic

T

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Mónica Ruiz-Casaresa, , José Ignacio Nazif-Muñozb a b

Department of Psychiatry, McGill University, Montreal, Quebec, Canada Institute for Health and Social Policy, McGill University, Montreal, Quebec, Canada

A R T IC LE I N F O

ABS TRA CT

Keywords: Child supervision Home alone Supervisory neglect Sibling care Laos Lao People’s Democratic Republic

Researchers have paid little attention to non-adult child supervision and the prevalence and factors influencing this practice in low-income countries. A better understanding of this phenomenon is needed to inform the development and implementation of policies and interventions to enhance child supervision in those settings. This study explores the prevalence and factors associated with young children being home alone or under the care of another young child in Lao People’s Democratic Republic. Using the 2011–2012 Lao Social Indicator Survey (N = 10,740 for the subsample of ‘child was home alone’ and N = 10,539 for the subsample of ‘child cared by another child < 10 years of age’), multi-level Poisson regressions were performed to determine the number of days children under five years of age were home alone or under the care of another child younger than 10 years of age. Large discrepancies across provinces and between urban and rural populations within each province were found. Children living in rural areas were more than five times more likely to be unsupervised than children living in urban settings (incidence rate ratio, IRR 5.2; 95% CI: 1.8–15.2), and children living in rural areas were nearly twice more likely to be under the care of another child than children living in urban settings (IRR 1.9; 95% CI: 1.3–2.8). Age was also a common factor in explaining variation in both dependent variables. Policies aimed at facilitating adequate child care and supervision should consider rurality to increase children’s protection.

1. Introduction Despite scarce empirical research in most countries, there is evidence that children around the world spend time at home alone (Dahlblom, Rodríguez Herrara, Peña, & Dahlgren, 2009; Ruiz-Casares & Heymann, 2009; Vandivere, Tour, Zaslow, Calkins, & Capizzano, 2003) or under the supervision of another young child (UNICEF, 2009). Sibling care, common in many societies (Lancy, 2008; Weisner et al., 1977), can have positive developmental outcomes for child caregivers, strengthen sibling ties, and allow other family members to attend to employment and other responsibilities (LeVine et al., 1994; Whiting & Whiting, 1975). However, it can also compromise the mental health and school performance of children caregivers (Yi et al., 2012), and the wellbeing of the younger children under their care (Morrongiello, Schell, & Keleher, 2013). There is evidence, for example, that children who are supervised by older siblings have a higher risk of childhood injuries than children who are supervised by their parents (Halawa, Barakat, Rizk, & Moawad, 2015; Morrongiello, MacIsaac, & Klemencic, 2007; Wang, Liu, Liu, Lin, & Shen, 2010). The use of inadequate substitute child care resulting in actual or potential harm, is usually considered problematic by child neglect scholars and practitioners in high-

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Corresponding author at: 7085 Hutchison, Office 204.2.14, Montreal, Quebec, H3N 1Y9, Canada. E-mail addresses: [email protected], [email protected] (M. Ruiz-Casares), [email protected] (J.I. Nazif-Muñoz).

https://doi.org/10.1016/j.chiabu.2018.08.001 Received 22 May 2017; Received in revised form 22 July 2018; Accepted 1 August 2018 0145-2134/ © 2018 Elsevier Ltd. All rights reserved.

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income countries (Coohey, 2003; Dubowitz et al., 2005)—where most of the neglect literature originates (Stoltenborgh, BakermansKranenburg, & van Ijzendoorn, 2013) and inadequate supervision is often the most common type of neglect (Sedlak et al., 2010; Trocmé et al., 2010). The context in which supervision takes place needs to be carefully examined. Multiple child, caregiver, and environmental factors act and interact to increase or reduce risk in cases of inadequate supervision (Morrongiello, Klemencic, & Corbett, 2008; RuizCasares, Trocmé, & Fallon, 2012; Schwebel & Gaines, 2007). Children’s greater maturity, limited parental availability, and perceived neighborhood safety, for example, are consistently related to non-adult supervision (Casper & Smith, 2004; Lopoo, 2005; Vandivere et al., 2003). Recognition of the seriousness of lack of supervision has led to the accumulation of a growing body of research, yet population-based data on this phenomenon are scarce. Aside from studies on unintentional child injuries (e.g., (Gyedu et al., 2015; Poudel-Tandukar et al., 2006), most of this evidence originates in urban settings in high-income countries. With a population of approximately 6.5 million people, one-third of whom are under 15 years of age, the Lao People’s Democratic Republic (Laos) is a country with great cultural diversity and rapid social change due to migration and economic growth (Lao Statistics Bureau, 2016; Phouxay & Tollefsen, 2011; Rigg, 2007). Despite rapid urbanization, 67% of the population still lives in rural areas and 8% do not have road access (Lao Statistics Bureau, 2016). Laos has made significant improvements in child mortality, exclusive breastfeeding, and other child wellbeing indicators in recent years, yet rural-urban disparities remain high in the country (ASEAN & UNICEF, 2016). Geographic location and limited infrastructure partly explains the comparative disadvantage of minority ethno-cultural groups in terms of access to public services such as health and education. Higher poverty rates among those groups further compounds the situation (Government of Lao PDR, 2006). In Laos, 87% of all households are headed by men (Lao Statistics Bureau, 2016). The average household size nationwide was 5.3 in 2015, with the largest households found in remote rural areas (Lao Statistics Bureau, 2016). More than half of the household members are children (Dommaraju & Tan, 2014). Throughout the country, child rearing is considered an extended family and even community responsibility. Following the descent rules of each ethno-cultural group (e.g., married Lao ethnic daughters live with their parents whereas Hmong and Khmu daughters move with their husband’s families (Kislenko, 2009)), family members often live close to each other and housing structures reflect this communal approach by having few private rooms. There has been very limited research on families, including child care, in Laos and even less research is available to an international audience. The 2006 Multiple Indicator Cluster Survey (MICS) in Laos revealed that children under 5 years of age were home alone (5.9%) or in the care of other children younger than 10 years (24%); children in rural areas were twice as likely to be without adult supervision than children in urban areas (Department of Statistics & UNICEF, 2008). In response to the need for a better understanding about child supervision in Laos, this study explores the prevalence of children 0–59 months who stayed home alone or under the care of another young child using data from the most recent Lao Social Indicator Survey (LSIS) (MoH & LSB, 2012). We assessed the factors that influence these child care arrangements across and within different geographical and socio-demographic groups in Laos. 2. Method 2.1. Data source The UNICEF-supported MICS are household surveys administered in low- and middle-income countries since 1995 (UNICEF, 2015). Originally administered every 5 years, MICS surveys are, since 2007, administered every 3 years. To date, more than 100 countries have participated in the MICS program, approximately 60 countries per round (UNICEF, 2015). Initially created in response to the World Summit for Children, MICS surveys have been expanded overtime to measure progress towards other international targets for children, women and men. To investigate supervision practices of children under the age of 5 years, we use the Lao Social Indicators Survey (LSIS) 2011–2012, a nationally representative, population-based household survey that covers child development and child protection among other substantive areas (MoH & LSB, 2012). The LSIS is conducted by the Ministry of Health and the Lao Statistics Bureau in collaboration with other ministries and with financial and technical support from UNICEF and the United Nations Population Fund. Although the LSIS combines items from the Demographic and Health Survey (DHS) and the MICS, all items use in our analyses came from MICS. The LSIS uses standardized questionnaires and two-stage cluster sampling with probability proportional to estimate cluster size (Hancioglu & Arnold, 2013). This survey is designed to provide health and other indicators at the national level, in both urban and rural areas for 17 provinces including Vientiane Capital. Urban areas, rural areas with road access and rural areas without road access within each province are identified as the main sampling strata and the sample was selected in two stages. The LSIS includes four questionnaires to collect information regarding household characteristics, women aged 15–49 years, men aged 15–49 years, and children. The latter is administered to mothers or caregivers for all children under 5 years of age living in the household and included two items measuring child supervision. These items elicit caregiver’s reported number of days in the week prior to the survey the index child had been (a) home alone for more than an hour and/or (b) left in the care of another child younger than 10 years of age, for more than an hour. Interviewers are trained not to convey judgement in the formulation of the question so as to provoke not-biased responses. The sample size for children under 5 years of age in the LSIS 2011–2012 was 11,067. This study uses two sub-samples from this survey: (a) ‘Child was home alone’ (n = 10,740) and (b) ‘Child was in the care of another child younger than 10 years of age’ (n = 10,539). The difference between the sample size for the LSIS 2011–2012 survey and the subsamples used in this study corresponds to the total number of individuals who simultaneously answered each question introduced in each model hereby analyzed. In Table 1 we observe the distribution of different variables associated with the two sub-samples under study. We report four 218

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Table 1 Percentage of child development variables associated with children under 5 years of age home alone and supervised by another child younger than 10 years. Variable

Child was left alone

Child was left in the care of another child younger than 10 years old

Child has been ever breastfed Yes

98.4

98.4

Child’s weight (Kgs) 0-7 7.1-14 More than 14.1

14.3 73.2 12.4

14.5 73.1 12.3

Early child development Literacy numeracy Physical Social-emotional Learning N

17.5 97.9 81.5 94.0 10,740

17.6 98.1 81.8 94.1 10,539

variables associated with child health and early child development (ECD): First, we observe that more than 98% of children have been breastfed, and more than 73% weight between 7 and 14 kg. We report four dimensions for ECD, which is defined as “an orderly, predictable process along a continuous path, in which a child learns to handle more complicated levels of moving, thinking, speaking, feeling and relating to others. Physical growth, literacy and numeracy skills, socio-emotional development and readiness to learn are vital domains of a child’s overall development” (MoH & LSB, 2012: 211). The total percentage indicates the proportion of children who are developmentally on track in each domain. Results show that most children are on track in three out of the four domains: physical, social-emotional, and learning, but only one of every five children in this age group is developmentally on track in literacynumeracy. 2.2. Study variables Two dependent variables are developed to reflect the number of days children aged 0–59 months spent, in the week prior to the survey, more than an hour (a) home alone and/or (b) in the care of another child younger than 10 years of age. Values for these variables range 0–7 (home alone) and 0–5 (cared by young child), representing the number of days in which the child was in each type of care arrangement. Explanatory variables include child’s sex and age (in months), number of children aged 2–12 years living in the household, number of individuals aged between 15–49 years living in the household, mother’s and father’s education, household’s Wealth Index Score (WIS), province (n = 17), and place of residence. Parental education is classified as: ‘None; ‘Upper secondary education and lower (including ‘Primary education,’ ‘Lower secondary education,’ and ‘Upper secondary education’), and ‘Higher education and other’ (including ‘Post-Secondary non-tertiary, education,’ and ‘Higher education’). The WIS incorporates household characteristics (i.e. electricity, water facilities, number of rooms, type of toilet, and built-material of roofs, floors, walls), presence of material goods (i.e. television, telephone, fridge) and ownership of a computer, camera, bank account among other goods. Place of residence is defined as ‘rural’ or ‘urban.’ According to the Lao’s census, which guides LSIS sampling, an urban village should have the following characteristics: (a) lie in the municipal vicinity where the district or provincial authority is located, there are more than 600 residents or more than 100 households, (b) there is a road for motor vehicles to get access to the village, (c), the majority of households in the village are electrified, (d) there is a tap water supply in service to the majority of households, and (e) there is a market in the village. 2.3. Statistical analyses Due to the hierarchical structure of the data and the operationalization of our two dependent variables, we employ a two-level random-effect Poisson regression analysis approach for two related subsamples (Larsen & Merlo, 2005; Merlo et al., 2006) with children (N = 10,740 for the subsample of ‘child was home alone’ and N = 10,539 for the subsample of ‘child cared by another child < 10 years of age’) in the first level and provinces (n = 17) in the second level. Since not all children who are home alone are also supervised by another child and vice versa, we opted for carrying out analyses separately. Combining the two sub-samples would have masked some associations and/or resulted in significant associations which may have not been present. Our approach also allows us to account for geographical variation due to these levels and to estimate correctly the variance for the parameter of interest (Rabe-Hesketh & Skrondal, 2008; Rabe-Hesketh, Skrondal, & Pickles, 2005). Data are analyzed in three stages. First, an empty model is constructed to assess whether child supervision varied from province to province. Second, we examine bivariate models for each variable of interest. Lastly, we introduce simultaneously all the covariates to examine their effects on child supervision. To examine the clustering of child supervision within provinces several indicators of variation or clustering are applied. First, we calculate the median odds ratio (MOR) and its 95 credible intervals (95%CrI). As stated by Merlo et al. (2006) and Larsen and Merlo (2005) the MOR translates the area level variance into a form similar to the OR by comparing all possible children chosen from each provinces, i.e. the MOR is the median of the ORs for all possible children and with the higher odds always placed in the numerator. 219

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The MOR is always ≥1, and if it equals 1 there is no variation in the prevalence of child supervision among provinces. The MOR can be computed using the following formula: MOR = exp[√(2xVA × 0.6745] ≈ exp(0.95√VA), where VA is the province-level variance and 0.6745 is the 75th percentile of the cumulative distribution function of the normal distribution, with a mean of 0 and variance of 1. Lastly, to capture whether there are differences within provinces in terms of rurality we carry out a Poisson analysis in which we introduce an interaction effect between province and rurality considering all the variables of the full models. All statistical analyses are done using Stata version 14.0 (Stata Corporation, College Station, TX, USA). For the specific multi-level modelling of provinces, we use the ‘xtpoisson’ function (Rabe-Hesketh & Skrondal, 2008). 2.4. Ethics approval The analyses hereby described are part of the study “Secondary Analysis of UNICEF-MICS Data on Child Care” approved by the McGill University Faculty of Medicine Institutional Review Board (A09-E84-09B). 3. Results 3.1. Profile of study population The two survey sub-samples capture a balanced number of boys and girls across the 17 provinces in the country; eight in ten lived in rural areas (Table 2). These statistics are in line with the overall distribution of children under 5 years of age in Laos (MoH & LSB, 2012). Children range in age between 0–5 years, with 2.5 years being the mean age for both sub-samples. On average, children live in households with 7 members aged 15–49 years. There is, however, large variation across age groups and household size/composition. One-fourth of mothers and one-in-six fathers do not have any formal education. 3.2. Prevalence of young children without adult supervision The large majority of children under the age of 5 years in Laos are supervised by adults or by other children aged 10 years or older (Tables 2 and 3). Nonetheless, approximately one in ten (n = 1136) children younger than 5 years are supervised by another child under 10 years of age, and 5.7% (n = 613) stay home alone for more than one hour a week. In terms of the number of days in which children are not supervised by adults, we observe that the group of children under 5 years home alone is mostly distributed under the Table 2 Descriptive statistics of study variables associated with the children < 5 years surveyed population. Child was left alone Variable

%

Dependent variables Number of days left alone Number of days left in the care of another child < 10 years old Independent variables Sex of child (ref female) Age of child (months) Wealth Index score of the household Place of residence (ref rural) Number of children living in the household between 2–12 Number of individuals living in the household between 15–49

Child was left in the care of another child younger than 10 years old

Mean

SD

Min

Max

0.1

0.6

0

7

49.0

%

Mean

SD

Min

Max

0.3

1.0

0

5

29.1 −0.3

17.4 0.9

0 −1.7

59 3.8

49.0 29.3 −0.2

17.4 0.9

0 −1.7

59 3.8

2.7

1.7

1

18

2.6

1.7

1

18

6.6

2.1

2

10

6.6

2.1

2

10

81.5

81.3

Mother's education * None (ref) Upper secondary education/lower Higher education/other

25.3 67.3 7.5

25.1 67.3 7.6

Father's education None (ref) Upper secondary education/lower Higher education/other N

15.9 73.1 11.0 10,740

15.7 73.1 11.2 10,539

Notes: *Mother's education refers to educational attainment of mothers and caregivers who care for a child that lives with them and is under the age of 5 years. 220

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Table 3 Percentages of children under 5 years of age home alone and supervised by another child younger than 10 years old by number of days. Number of days

0 1 and 2 3 and + Total

% child was left alone

% child was left in the care of another child younger than 10 years old

Age 0-2

Age 3-4

Age 0-4

Age 0-2

Age 3-4

Age 0-4

%

N

%

N

%

N

%

N

%

N

%

N

96.7 2.4 0.9 100

6,236 156 51 6,443

90.5 6.5 3.0 100

3,891 279 127 4,297

94.2 4.1 1.7 100

10,127 435 178 10,740

92.1 4.0 3.9 100

5,857 258 247 6,362

84.9 7.3 7.8 100

3546 305 326 4,177

89.3 5.3 5.4 100

9403 563 573 10,539

category 1 and 2 days (4.1%) (n = 422) whereas for the group of children who stay under the care of another child younger than 10 years, the distribution is rather balanced between those who stay in this arrangement for 1 and 2 days (5.3%, n = 563) and for 3 days or more (5.4%, n = 573). Most children home alone are found in the furthest Northern and Southern provinces (Fig. 1). The prevalence of children home alone ranges from 0.6% in Borikhamxay to 14.0% in Saravane provinces. Other than Saravane (20.7%) and Sekong (21.4%) in the South, the highest prevalence of children cared by another child younger than 10 years of age is found in the North of the country, particularly in Luangnamtha (22.5%) and Huaphanh (25.0%) (Fig. 2).

Fig. 1. Percentage of children left alone per province (2011–2012). 221

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Fig. 2. Percentage of children left in the care of another child younger than 10 years old per province (2011–2012).

3.3. Factors associated with lack of adult supervision Several factors seem to influence the practices under study across the different provinces in the country (Table 4). Our bivariate models suggest that both ‘home alone’ and ‘cared by another child < 10 years of age’ are associated with the same independent variables: age, wealth, place of residence, number of children aged 2–12 years living in the household, mother’s education, and father’s education. Our adjusted models overall suggest that age and place of residence stand out as common factors in explaining variation in both dependent variables. Children are more likely to be in non-adult care as they age. Both arrangements are used more frequently with 3–4 year-old children than with younger children. This can be confirmed in the distribution of these variables by age displayed in Table 3. Province is also a significant factor in explaining variation in both dependent variables, confirming the need of analyzing this phenomenon with a multi-level approach. In fact, in both adjusted models we observe the MORs to be higher than 1 (Table 4). Large discrepancies between urban and rural populations and across provinces also exist. Children living in rural areas are more than five times more likely to be unsupervised than children living in urban settings (incidence rate ratio, IRR 5.2; 95% CI: 1.8–15.2), and children living in rural areas are nearly twice more likely to be under the care of another child than children living in urban settings (IRR 1.9; 95% CI: 1.3–2.8). Figs. 3 and 4 clearly show the wide variation in the use of non-adult care across provinces and rural/urban settings. Except for Huaphanh, Vientiane, and to a lesser extent, Khammuane and Xiengkhuang provinces (Fig. 3), the probability of leaving a child home alone is consistently higher in rural than urban areas. In Fig. 3 we also observe that the confidence interval corresponding to the province of Borikhamxay surpasses the lower bound of probability because only 3 children out 520 were home alone. Leaving children with other children is also more prevalent in rural settings. However, this pattern is not observed in Bokeo, Borikhamxay, Khammuane, Phonsaly, and Xayabury provinces (Fig. 4). Statistical difference was significant (p < .05) within Huanphanh for home alone and Khammuane for children with other children only. 222

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Table 4 Association estimates linking individual and provincial variables with ‘Number of days home alone’ and ‘Number of days in the care of another child younger than 10 years old’ from the Lao Social Indicators Survey in 2011–2012. Home alone Variable

Null models

Bivariate model

Adjusted model

Null model

Bivariate models

Adjusted model

IRR

IRR

CI

(95%)

IRR

CI

(95%)

IRR

IRR

CI

(95%)

IRR

CI

(95%)

0.8 1.0 0.6

0.7 1.0 0.5

1.0 1.0 0.8

0.8 1.0 0.9

0.7 1.0 0.7

1.0 1.0 1.1

0.8 1.0 0.6

0.7 1.0 0.5

1.0 1.0 0.6

0.8 1.0 0.8

0.7 1.0 0.6

1.0 1.0 0.9

6.1 1.0

2.5 10

14.8 1.1

5.2 0.9

1.8 0.8

15.2 1.0

2.8 1.1

2.1 1.1

3.9 1.2

1.9 1.1

1.3 1.0

2.8 1.2

0.9

0.9

1.0

1.0

0.9

1.0

0.9

0.9

1.0

0.9

0.8

0.9

0.6

0.4

0.9

0.8

0.6

1.2

0.6

0.5

0.7

0.8

0.7

1.0

0.4

0.3

0.6

1.6

0.6

4.2

0.3

0.1

0.6

0.8

0.3

1.8

0.6

0.5

0.8

0.9

0.7

1.1

0.7

0.6

0.9

1.0

0.8

1.2

0.2

0.1

0.5

0.5

0.2

0.9

0.3

0.2

0.4

0.8

0.5

1.3

CI

(95%)

Sex of the child (ref female) Age by months Wealth Index score of the household Place of residence (ref rural) Number of children aged 212 years living in the household Number of individuals aged 15-49 years living in the household Mother's education (ref none) Upper secondary education and lower Higher education and other Father's education (ref none) Upper secondary education and lower Higher education and other Measures of variation or clustering Province level variance (SD) MOR (95% Crla) N

Cared by another child < 10 years old

0.4 (0.2) 1.8 (1.4-2.8) 10740

0.4 (0.2) 1.9 (1.8-2.0)

CI

(95%)

0.4 (0.1) 1.8 (1.7-1.9) 10539

0.3 (0.1) 1.4 (1.3-1.4)

Notes IRR = incidence rate ratio CI = confidence interval; SD = standard deviation; MOR = median odds ratio; CrI = credible interval. interval contains 1, there are no differences across provinces. Bold numbers indicate statistically significant association (p < 0.05).

a

If the

Fig. 3. Probability of leaving a child home alone across and within provinces.

Richer households are less likely to leave young children under the care of other young children (IRR 0.8; 95% CI: 0.6-0.9), but not home alone (IRR 0.9; 95% CI: 0.7–1.1). Regarding parental education, only households where mothers have completed up to upper secondary education are less likely at p. = 0.055 to leave children home alone or with other young children than households where mothers have no formal education (IRR 0.8, 95% CI: 0.7–1.0). Compared to children whose father has no formal education, 223

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Fig. 4. Probability of leaving a child in the care of another child across and within provinces.

children of fathers who have completed higher education are less likely to be home alone (IRR 0.5, 95% CI: 0.2-0.9), yet no difference is found for children in the care of another child (IRR 0.8, 95% CI: 0.5–1.3). ‘Number of children aged 2–12 years living in the household’ and ‘number of individuals aged 15–49 years living the household’ are not associated with significant values when describing leaving children home alone. However, these two variables have significant values and opposite directions when studying children cared by other young children. Households with more children are more likely to leave a child supervised by another child (IRR 1.1, 95% CI: 1.0–1.2) and households with more adults are less likely to leave a child supervised by another child (IRR 0.9, 95% CI: 0.8-0.9). Lastly, gender does not seem to influence these practices. 4. Discussion This study is one of very few to analyze cross-sectional data on child supervision in a low-income country, and the first one in Laos. Our study shows that the large majority of young children in Laos are supervised by adults and/or by children who are at least 10 years-old (96.5%). Nonetheless, 13.9% of surveyed caregivers disclosed leaving a child under 5 years of age home alone or under the care of another child younger than 10 years of age for over an hour at least one day in the week prior to the survey. In some cases, this may be a regular practice, as almost 2% of children were home alone and 5% were with another young child 3 or more days in the week preceding the survey. Rurality is the most important factor in explaining variation in children home alone or with another young child. Our study found that children living in rural areas are more than five times more likely to be unsupervised and nearly twice more likely to be under the care of another child than children living in urban settings. This may be partly explained by the demands of agriculture and other subsistence work on all able household members, sibling care as a social value, and increasing rural-urban migration. On the one hand, adult caregivers need to tend to the fields, go sell in the market, or be occupied with employment elsewhere. On the other, sibling care is socially encouraged. Children are also being left behind in the family home alone or with grandparents/other relatives, particularly in Southern rural communities, by migrant working parents in search for employment in cities and nearby countries (Janson, 2014; Phouxay & Tollefsen, 2011; Rigg, 2007). As others have shown (Heymann, 2006; Ruiz-Casares & Heymann, 2009), lack of (accessible) alternative family support services (e.g., daycare centres) in certain communities and reliance on informal employment may also explain parents’ limited choices to leave children home alone or with other children. Disparities between rural and urban areas confirm the need for policies aimed at facilitating child care to consider these settings. This is further compounded by the need to provide equal opportunities and supports to ethnic groups living in remote areas (Government of Lao PDR, 2006). Special attention to these settings and particularly vulnerable populations is paid in the most recent 5-year Laos National Development Plan (2016–2020) (MPI, 2016). Although no mention is made directly to child supervision, a number of family and community issues addressed by this plan may be linked to it—from illicit drug use and school dropouts to road traffic crashes and human trafficking (Deb, 2015; Fatimah, Osman, Masyarakat, & Perubatan, 1997; Lowe & Dotterer, 2013; Pless, Verreault, & Tenina, 1989; Ryan, Williams, & Courtney, 2013). Regional differences in availability and access (infrastructure) to services to support families, may also explain study findings (MPI, 2016). Future studies should also sample across provinces that show a reverse pattern (i.e., more non-adult supervision in rural than in urban areas) to advance our understanding of the underlying determinants of non-adult supervision. One element to explore further is the variable parents’ education. Higher likelihood of young children being home alone whenever parents have no formal education or children being under the care of another young child in households where the mother has no 224

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formal education raises additional questions for study and provides guidelines for future action. One aspect of this association to explore further is the age distribution of parents within same education groups. Our analyses do not suggest that this interaction holds for the case of Laos (see Appendix A in Supplementary materials). It is also possible that widespread social norms that value boys more than girls (UNICEF, 2014) and condone early marriage, particularly among ethnic minority girls, indirectly contribute to these findings and require further study (Kislenko, 2009). Women are responsible for child rearing and taking care of the household, often with limited or no assistance from their husbands (Alvesson, Lindelow, Khanthaphat, & Laflamme, 2013; UNICEF, 2014). This, on top of their contributions to the financial maintenance of their households, is no small task considering large household sizes. As for fathers, their highest level of education acted as the strongest protective factor. Children whose fathers had completed higher education were less likely to be home alone compared to children whose fathers had no formal education. Other studies have also found an association between parent’s educational status and children’s use of self-care. While in some settings more years of schooling is related to a higher likelihood of self-care (Vandivere et al., 2003), in many LMICs, the trend is frequently inversed (RuizCasares, Oulhote, Tran, & Bolduc, 2016). These variations also suggest that leaving a child home alone and leaving a child supervised by another child respond to different household dynamics and they are two different phenomena that require separate consideration even if certain characteristics make them to overlap. More specifically, more studies are recommended to identify why adults may be opting for one arrangement over the other, and whether this has an impact on how often these arrangements are used. For instance, the presence of another child may be considered by the adults in the household to be a viable option since these children may be perceived as subjects with capacities to care for their siblings. Indeed, Lao children are taught at a very young age to be independent, to take care of their even younger siblings, and to help with other tasks at home (e.g., collecting firewood and water and feeding the animals) and on the farm or family business (Kislenko, 2009; Ruiz-Casares, 2013; Xiong, Eliason, Detzner, & Cleveland, 2005). This is particularly relevant if we consider that firewood is still the most frequent cooking fuel (66.9% of households) and only 6.6% of households have access to piped water (Lao Statistics Bureau, 2016). Caregivers’ common misconceptions of young children’s skills and ability to be safe need be combatted with safety regulations and education (Peden et al., 2008). Educating caregivers, including older children, of the risks of lack or lapses of supervision (e.g., for bathing and water safety, for storing flammable substances in the home, road traffic safety, etc.) is an important step in protecting children (Hyder, Wali, Fishman, & Schenk, 2008). Safety education and interventions to influence the quality of supervision provided by all caregivers—children and adults—may also contribute to safer environments for children (e.g., safety education at schools (Wang et al., 2010). Our analyses showed that the number of children aged 2–12 years and individuals aged 15–49 years living in the household were associated with significant variation in children supervised by another child. On the one hand, parents often expect older children to supervise younger ones when their time is limited due to employment or household chores (Morrongiello et al., 2013). As such a relatively large number of children in the household can be regarded as an opportunity for parents to share their child supervision role. On the other hand, the presence of adults in a household would decrease the chances that children supervise other children because parents are likely to prefer individuals who they think can provide better supervision. These two findings do not contradict each other, though. It is plausible that households with large number of children may not have a large number of adults or vice versa. However, in the event in which households have both a large number of children and of adults, parents are less likely to live children supervised by other children. Whereas parents’ perception of children’s ability to care for themselves may vary between parents with more and less formal education, in contexts of limited resources, the decision may not reflect (solely or primarily) that parental assessment but rather a number of other factors affecting caregivers’ ability to devote undivided attention to children including the need to provide for the basic needs of the family. Poorer households often have more children to be cared for and fewer resources to do so as able household members—including young children, are needed to perform other competing household tasks (Peden et al., 2008). The extent to which this may explain our finding that richer households are less likely to leave children under the supervision of another young child is unclear and calls for further study. Other studies in low-income countries have found caregiver engagement in hourly work was linked to increased unintentional injuries in children, possibly due to lack of supervision (Gyedu et al., 2015). Moreover, economic circumstances may lead some parents to migrate in search of employment (e.g., to Thailand) leaving children in the care of grandparents or other siblings (Mazzucato et al., 2015; Wen & Lin, 2012). The establishment of community programs to ensure child supervision while parents are at work and school-age children attend classes as well as of safe play areas is recommended, as inadequate supervision can increase risks already identified by children in Laos (Ruiz-Casares, 2016). In Laos, a recent study casts light on the consequences of lack of adult supervision (Ruiz-Casares, 2016). In this study, qualitative analysis of children’s perspectives showed that children as young as 7 years of age in both urban and rural areas recognize that playing close to the roads and near the rivers without adults around is dangerous since road crashes and drowning can occur. Despite a growth in the numbers of daycare centres (mostly in urban settings) and extended classes in rural areas in Laos, parents are left with the difficult decision of whether to earn income in order to feed their children or to stay home supervising them. Indeed, often leaving children home alone is not really a choice on the part of parents but rather the result of limited options and supports. Hence the need to consider society’s responsibility in supporting working families in providing adequate child care (e.g., flexible sick and parental leave) (Ruiz-Casares & Heymann, 2009). Child’s age is also a common factor influencing supervision practices in Laos. More specifically, an increase of one month is associated with 4% of probabilities of leaving the child alone (IRR 1.04, 95% CI: 1.03–1.05) and 2% (IRR 1.02, 95% CI: 1.01–1.02) of leaving the child under the care of another child younger than 10 years of age. This is in line with other countries, as research consistently shows that children are less likely to be supervised by adults as they age (Ruiz-Casares et al., 2016; Vandivere et al., 2003). As we could appreciate in Table 1, widespread support for maternal breastfeeding in Laos seems to contribute as a protective 225

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mechanism for babies and very young children. According to the new Labour Law (2013), a woman is entitled to at least 105 calendar days of fully paid maternity leave, at least 45 of which must be after the birth, and one hour a day to feed and care for the child for a year after the birth (Arion Legal, 2014). The World Health Organization recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond (WHO, 2016). Extending the policy to include at least 6 months in line with international breastfeeding guidelines and to support the majority of mothers in Laos who work in the informal sector, emerge as action areas for the upcoming years. Also needed are studies in Laos that look at supervision in a broader group of young people. The LSIC only inquires about the care and supervision of children younger than 5 years. However, there is accumulating evidence that inadequate supervision can have serious consequences for children across all age groups. For example, less supervision during adolescence has been linked to increased risk of drowning (Linnan et al., 2007) and transport-related injuries (Xiong & Mannering, 2013). Some children and adolescents, such as those with pre-existing mental health problems (Ruiz-Casares, Rousseau, Currie, & Heymann, 2012), may be particularly vulnerable to spending time home alone; yet such research is still lacking in Laos. In Laos, the proportion of children under five years of age who spent time home alone remained stable between 2006 (Department of Statistics & UNICEF, 2008) and 2011–2012 (MoH & LSB, 2012) (5.9% and 6.0%, respectively). In contrast, the proportion of households leaving a child with another child under the age of 10 years was reduced by half in the same time period (i.e., from 24.0% to 12.1%) (the percentage (12.1) of households leaving a child with another child under the age of 10 years is slightly higher than our results because we report the sub-sample of the adjusted models), and while all provinces observed a decreased in this characteristic, the reduction in the Southern ones was the least pronounced (from 21.6% to 14.6%). Although changes in wording of these items in the two surveys may partly explain this reduction (UNICEF, 2018), more studies are needed to better understand the context in which lack of adult supervision occurs in Laos and identify factors that may help increase child supervision. Relatedly, the contextual appropriateness of these items in different settings, including local understandings of the expression “home alone” across ethnolinguistic groups, needs further assessment. For example, wherever several families share the same living space or houses are arranged in such a way that there is hardly any private space to leave a child completely unnoticed by others. Ethnographic study—including observation of housing arrangements and child-care practices in diverse settings is recommended to validate the appropriateness of the items and to explore the role that ethnicity and culture play on the ways supervision is conducted. Beyond the scope of our study, exploratory analysis of ethnicity in this sample (see Appendix B in Supplementary materials) also reinforces the importance of considering the reality of different cultural groups in future quantitative studies of child supervision in Laos. This information is crucial to inform culturally-sensitive interventions and evaluations to support children and families (Hafford, 2010). These important efforts to understand child supervision more systematically in Laos need to be tempered. First, cross-sectional data prevent us from drawing causal inferences. Second, this being a household survey, its results cannot be generalized to the entire population that includes children living in residential care or in the streets. Third, lack of information on factors elsewhere linked to non-adult supervision (e.g., parental employment and childhood injuries) prevented analyses on how those may have influenced the results. Information regarding the number and type of daycare centres, or institutions designed to supervise children lower than 5 years of age across the country is very limited too. This could contribute to the variation in both of our dependent variables. Fourth, by relying exclusively on one caregiver to report on the behaviour of all caregivers in the household, there may have been some underreporting due to social desirability or problems with recall. This is despite attention to interviewer training and supervision, including emphasis on non-judgemental formulation of questions.

5. Conclusion In the absence of studies that use nationally representative samples from LMICs to study child supervision, this study makes a unique contribution to the literature on the unmet basic needs of children (Dubowitz et al., 2005) and provides a solid platform to further investigate risks to children involved in these practices. Our study provides evidence that there are young children in Laos who are home alone or under the care of children under 10 years of age. Children living in rural areas and older children (≥3 years) are significantly more likely to be unsupervised or with other young children than children in urban settings or aged 0–2 years. It will be important for future research to assess the contextual validity of these items and to investigate cultural beliefs and practices on child supervision as well as the direct and indirect impact of these arrangements on the wellbeing and later life outcomes of child caregivers and supervisees, their families and communities. This information is needed to design and implement appropriate policies and interventions aimed at promoting child wellbeing and preventing harm due to lack of adequate supervision in LMICs.

Conflict of interest The authors declare that they have no conflict of interest.

Acknowledgements The authors were supported by a Research Scholarships from the Fonds the recherche en santé du Québec (Ruiz-Casares) and a Steinberg Global Health Postdoctoral Fellowship from McGill University (Nazif-Muñoz). 226

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