adoption research studies

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• 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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Margaret F. Keil, Adela Leahu & Constantine A. Stratakis

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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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Consent for participation in this study was obtained from the legal guardians of the participating children.

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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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Received : 02 September 2020

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Accepted : 02 December 2020

Published : 26 May 2021

Issue Date : May 2022

DOI : https://doi.org/10.1038/s41390-020-01325-1

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What Behavioral Genetics Teaches Us About Adoption

How nature and nurture interact..

Posted August 2, 2020

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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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You can feel prepared and confident on your way to successfully completing the adoption home study with our support. As a fully licensed California home study provider, we will provide the services you need every step of the way.

Helpful Information

Newborn adoption, foster care, international adoption.

Regardless of the type of adoption you choose or the adoption professional you work with , the home study is one of the most important steps you will take in the adoption process — and FCCA can provide the services you need to complete yours.

California law requires all prospective adoptive parents to complete an adoption home study. The purpose of the home study in California is to:

• Confirm that the family is able to provide a stable, nurturing home to a child
• Help the social worker understand the types of adoption opportunities that would be appropriate for the family
• Answer the family’s questions and help prepare them for parenthood

Although some families may feel overwhelmed by the home study for adoption, this is an exciting part of the adoption process that gets you one step closer to becoming a parent.

Whether you are adopting through one of our programs or through another child-placing agency, FCCA is licensed and Hague-accredited to provide a domestic or international home study in California.

To get more adoption information now, you can contact us online at any time. Meanwhile, learn all you need to know about the adoption home study in California.

The Home Study for Adoption in California

Each state has different laws for  home study processes and requirements . The adoption home study in California includes:

• Individual interviews with each adoptive parent
• A home visit with all adults living in the home
• Fingerprint-based background checks
• Paperwork regarding finances, health and employment
• Documentation such as birth certificates, marriage/divorce certificates and character references

The California adoption home study will not be approved if any adult living in the home has been convicted of:

• A felony for child abuse or neglect, spousal abuse, a crime against a child or a crime involving violence, including rape, sexual assault or homicide
• A felony within the past five years for physical assault, battery or a drug- or alcohol-related offense

Although the adoption home study requirements are generally the same for most domestic adoptions, some other countries have additional requirements for international adoption home studies . If you are adopting internationally, then we will work with you and your child-placing agency to ensure your home study meets that country’s standards.

Although there is no such thing as a free home study for adoption, California offers the Adoption Assistance Program for families worried about the costs. This program includes a monthly subsidy and medical coverage, such as Medicaid or Medi-Cal for eligible children.

FCCA offers several adoption preparation classes, which include more detailed information about the adoption process and home study requirements. Your intake interviewer will provide more information about the adoption home study before beginning the process.

So, if you’ve been wondering, “Where can I find home studies for adoption near me,” then FCCA can help you out. Contact us online today.

What to Expect During the Home Study Interview

Once you have submitted the required adoption paperwork to FCCA, your social worker will schedule individual interviews with you and your partner, if applicable. These interviews take place at the agency office during regular working hours and generally last about two hours each.

These interviews give your social worker a chance to get to know you better and ensure that you and your partner share similar adoption goals and attitudes. During the interview, you might discuss:

• Your family background and childhood
• Your current family dynamics, values and traditions
• Your career, education and interests
• Your lifestyle and hobbies
• Your neighborhood and community
• Your experience with children and parenting style
• Your reasons for adopting
• Your attitudes toward adoption and adopted children
• Your knowledge about adoption issues

Remember, there are no “right” or “wrong” answers during the adoption home study interview. These interviews allow your social worker to get a better understanding of your family and the types of adoption opportunities you seek.

What to Expect During the In-Home Visit

In addition to your individual interviews, your social worker will schedule a time to meet with all adult members of your household. This visit will take place on a weekday during regular working hours.

During this visit, your social worker will conduct an adoption home study inspection, ask you some more questions and speak with other members of your family. Many hopeful parents are nervous about the home visit, but remember that your home does not need to be spotless, and you are not expected to be perfect.

Although you need to meet certain safety standards as outlined by California adoption laws , the social worker is there to make sure your house is generally safe and appropriate for a child.

Post-Placement Visits in California

After a child is placed in your home, you will undergo at least six months of post-placement supervision before the final adoption decree is granted.

In California, the post-placement supervision includes at least one in-home visit with the adoptive parents and child and three more visits with the adoptive parents that may occur outside of the home. During these interviews, your social worker will ensure you and the child are adjusting well to the placement and will offer any post-placement services or support you need.

Ready to Begin the Adoption Home Study in California?

Whether you are completing an international, foster care or domestic infant adoption, you will need to complete a home study for adoption. When you are ready to begin the  adoption home study process , or if you need more information about our home study services,  contact your nearby FCCA office  to get more free information now. 

Frequently Asked Questions About Adoption

1. What is adoption?

Adoption is a legal process which permanently gives parental rights to adoptive parents.  Adoption means taking a child into your home as a permanent family member.  It means caring for and guiding children through their growing years and giving them the love and understanding they need to develop their full potential.

2. How do agency adoptions, independent adoptions, and intercountry adoptions differ?

In an agency adoption, a public or licensed private adoption agency or a CDSS Adoption Regional Office places the child for adoption.  The birth parent's parental rights are terminated either by court order or by the filing of a relinquishment.  The adoption agency becomes legally responsible for the care, custody and control of the child.  The agency studies and approves adoptive applicants before placing a child in their home for adoption, then supervises the placement for six or more months before the court approves the adoption.

In an independent adoption, birth parent(s) choose the prospective adoptive parent(s) and place the child directly with them.  When making this decision, a birth parent must have personal knowledge of certain facts about the prospective adoptive parent(s).  The birth parent(s) placing the child for adoption must receive an advisement of rights, responsibilities, and options from an Adoption Service Provider (ASP).  The birth parent(s) must also sign an Independent Adoption Placement Agreement (AD 924) , which in 30 days automatically becomes an irrevocable consent to adoption unless revoked within that time.  Please note, in most cases, the Independent Adoption Program may not be utilized for the adoption of foreign-born children.  Most adoption petitions involving a foreign-born child are statutorily defined as intercountry adoptions.  As a result, the CDSS Adoption Regional Office or a delegated county adoption agency lacks the authority and necessary credentials to investigate or conduct an intercountry adoption using the Independent Adoption Program.  Thus, the Intercountry Adoption Program is the proper channel for proposed adoptions of foreign-born children.  For additional information about adopting a foreign-born child through the Independent Adoption Program please review  All County Letter 20-69 .

In an intercountry adoption, prospective adoptive parent(s) adopt foreign-born children for whom the federal law makes a special immigration entry visa available.  Intercountry adoption includes completion of the adoption in the child's native country or in California.  For more information see question #14 below.

If you have any questions regarding the Independent or Intercountry Adoption Programs, please e-mail  [email protected] .

3. About the children!

Foster children of all ages are in the child welfare system awaiting permanent homes.  Parental rights to these children have been terminated by court order.  The county or the CDSS Adoption Regional Office selects permanent homes in which to make an adoptive placement.  Potential adoptive parents are informed of special needs or significant problems which the child may have or encounter.  Information provided by the child's caseworker depicts the child and describes the adjustments and challenges the child will have to overcome once placed with an adoptive family.

In an effort to use the power of the Internet and to bring children and families together, the California Kids Connection program was developed as California's registry of children waiting to be adopted and families wanting to adopt.  The program offers both a secure website accessible only to California licensed adoption agency personnel and a public site accessible to any Internet user.  The public site is available to anyone using the internet.  Visitors to this area of the website may view and indicate their interest in specific children by sending an immediate email to the adoption agency identified for each child.  This site features children for whom legal clearance has been granted by the court.

4. How do I find a child, and how do I adopt a child?

If you would like to adopt a child, contact your local public adoption agency or CDSS Adoption Regional Office to speak with an agency representative about the adoption process which will include an orientation.  After the orientation, if you make the decision to adopt, you must complete and submit a written application and the agency will assign an adoption caseworker to discuss the type of child you wish to adopt and the children that are available through the public adoption agency.  You must participate in a "family assessment" which consists of a thorough review of your criminal, medical, employment, emotional, marital, life history, and your home environment, as required by law.  This process is a joint effort by the agency and the adoptive applicants.  The agency evaluates and determines your ability to provide a stable, safe, and permanent home to a child who is available for adoptive placement.

You may also wish to consider adoption through a licensed private adoption agency.  You will need to contact licensed private agencies in your area for information about their services, requirements, and fees.

Please see question #3 above to view children, via the internet, who are waiting to be adopted.

To obtain a copy of licensed California adoption agencies, please review the  Directory of Public and Licensed California Adoption Agencies  or call 1(800) KIDS-4-US.

To locate a CDSS Adoption Regional Office, please visit the  CDSS Adoption Regional Offices website .

5. What ages of children are available-do you have any babies?

The ages of children available for adoption vary from county to county.  Persons wishing to adopt infants may expect to wait some time for their application to be selected, as most agencies have many homes already approved and waiting for the placement of infants.

6. How much will it cost to adopt?  Do we need an attorney?

In an agency adoption, the public adoption agency or CDSS Adoption Regional Office requires that you pay a fee of no more than $500 prior to submitting a favorable report to the court.  This fee may be deferred, reduced, or waived under certain conditions.  You should also expect to pay for fingerprinting, medical examination, court filing, and other adoption-related costs that usually total no more then $100-$300.

Families who adopt children who are eligible for the Adoption Assistance Program may qualify for the Non-recurring Adoption Expense Program.  The program reimburses families for adoption related expenses that they incur during the adoption process.  The amount of reimbursement is limited to $400 per child.  For more information regarding this program, please contact your local county adoption agency or a CDSS Adoption Regional Office.

Please note:   Fees for services rendered by licensed private adoption agencies are not regulated by the State and may vary.  You should ask about the fee schedule when you initially contact the adoption agency.

Adoptive parents may qualify for a federal tax credit for certain expenses paid to adopt an eligible child with special needs and a state tax credit for adopting a child who was in the custody of a California public child welfare agency.  For further information about the federal adoption tax benefit, contact the Internal Revenue Services (IRS) at 1-800-829-1040 and request Publication 968 or visit the IRS website .  For further information about the state tax benefit, contact the California Franchise Tax Board at 1-800-852-5711 and request information on Credit for Child Adoption Costs - Tax Credit Code 197 or visit the California Franchise Tax Board website .

The fee for the cost of the investigation of an Independent adoption petition is $4,500.  The fee may be reduced under certain circumstances.

The fee for the cost of the investigation of an Independent Adoption petition for a family with a completed, approved pre-placement evaluation is $1,550.  The pre-placement evaluation must meet the requirements of Family Code Section 8811.5.

Services of an attorney are generally not necessary in an agency adoption.  Although independent adoptions can be done without the involvement of an attorney in some instances, the involvement and consultation of a legal professional is generally desirable to ensure all legal requirements are met and the rights of the parties to the adoption are protected.

7. Is there financial assistance provided once the adoption is final?

The Adoption Assistance Program  can provide financial assistance and some medical coverage for many of today's waiting foster children.  This assistance may continue until the child is age 18, or in certain circumstances, age 21.

8. Both of us work.  Will I have to quit my job if I want to adopt or be a foster parent?

NO.  Both parents may be working as long as appropriate childcare arrangements are made.  The State also enacted new legislation which extends disability compensation to allow individuals who take time off work to bond with a new child.  Visit the Paid Family Leave for Adoptive or Foster Parents website  for more information.

9. I don't own my own home, or I live in an apartment.  May I adopt?

YES.  You don't have to own a house to give a home.  You may rent or own as long as your home is safe and has enough room for family members.  What is most important is the love, understanding, and guidance you can offer a child.

10. May single persons adopt?

Yes, single individuals may also adopt.  In fact, approximately one-fourth of the children adopted from the public foster care system are adopted by single individuals.

11. How long will it take to adopt a child?

In an agency adoption, depending on the workload of the agency selected, it may take anywhere from six months to a year to complete an adoption family assessment.  Most adoptive placements occur one to several months after the family assessment has been approved.

In an independent adoption, the process will vary based on when the prospective adoptive parents have been chosen by birth parent(s).  However, the CDSS Adoption Regional Office or delegated county adoption agency must investigate the proposed adoption within 180 days after they receive a copy of the filed petition and 50 percent of the adoption fee.

In an intercountry adoption, the process will vary with each country.  You should contact a private adoption agency licensed to provide these services in the county where you reside to inquire about the length of the process.

12. How can I get referrals to appropriate agency/county adoption offices?

The  Directory of Public and Licensed California Adoption Agencies  is available as a PDF.  It may also be obtained by calling 1-800-KIDS-4-US or writing to:

California Department of Social Services Adoption Services Branch 744 P Street, MS 8-12-521 Sacramento, CA 95814

13. What are interjurisdictional placement requirements?

In 1999, California enacted statutes that implemented interjurisdictional adoption provisions.  These provisions specify that the placement of a child for adoption may not be delayed or denied because the prospective approved adoptive family resides outside the jurisdiction of the CDSS Adoption Regional Office or the licensed adoption agency.  Such an adoptive family is one who is approved by an authorized entity in the state of residence in accordance with California standards.

It is also indicated in statute that if a person alleges there was a denial or a delay in the placement of a child for adoption based solely because they live outside the jurisdiction of the CDSS Adoption Regional Office, they will be accorded an opportunity for a state hearing.

14. If I find a child in another country, how can I adopt them?

Through the Intercountry Adoption Program, licensed private adoption agencies are specially licensed to assist California residents in adopting foreign-born children.  The licensed private adoption agency will assist you in completing the home study that is required for all Hague and Orphan adoption cases, as well as prepare you for the different requirements to adopt based on the child’s country or origin.  United States Citizenship and Immigration Services (USCIS) has final approval in determining the eligibility and suitability of the prospective adoptive parent(s) looking to adopt and the eligibility of the child to immigrate to the United States (U.S.).

There are three processes for adopting a child internationally:  1) Hague; 2) Orphan (non-Hague); and 3) Other Adoption Related Immigration.  Each process is distinct and has different eligibility requirements.   I am a U.S. Citizen...How Do I Help My Adopted Child Immigrate to the U.S. or Become U.S. Citizen guide explains the three different ways to adopt a child born abroad.  Before a child immigrates to the U.S., the child will need an immigrant visa.  The type of visa the child is issued will determine what steps you need to take for the child to acquire U.S. citizenship.  For more information on citizenship for an adopted child, visit the U.S. Citizenship for an Adopted Child website .  For more information on the process of intercountry adoptions, please visit the USCIS Adoption website .

In California, if the adoption of the child is full and final in the child’s country of origin, the child will need to be readopted in California per Family Code Section 8919 .  To obtain more information about California's Intercountry Adoption Program requirements, contact a private adoption agency licensed to provide these services in the county where you reside.

If you have any questions regarding the Intercountry Adoption Program, please e-mail [email protected] .

Through the Intercountry Adoption Program, licensed private adoption agencies are specially licensed to assist California residents in adopting foreign-born children who are classified as orphans by the Bureau of Citizenship and Immigration Services (BCIS). Individuals must file with the BCIS regional office that serves the area where they live, the BCIS form I-600A ("Application for Advance Processing of Orphan Petition") before a child to be adopted has been identified. They must also file a BCIS form I-600 ("Petition to Classify an Orphan as an Immediate Relative") after the child has been identified. For details, view the website at www.bcis.gov or contact the BCIS National Customer Service Center at 1-800-375-5283. You may order the informational brochure "The Immigration of Adopted and Prospective Adoptive Children" (M-249N) revised in September 2000 by calling 1-800-870-3676. The Child Citizenship Act (CCA) of 2000, entitles most foreign-born children adopted by U.S. citizens to acquire U.S. citizenship automatically on the date they enter the United States as lawful permanent residents without the need to apply for citizenship.

The child must meet the following BCIS requirements:

• At least one adoptive parent is a U.S. citizen,
• The child is under the age of 18,
• The adoption of the child has been finalized,
• The child is a U.S. lawful permanent resident, and
• The child is residing permanently in the United States in the legal and physical custody of the United States citizen parent.

If you are finalizing an adoption or have to re-adopt a foreign-born child after he or she has been admitted to the United States as a lawful permanent resident, the child automatically will become a citizen on the day he or she meets all of the above requirements. If you want to have documentation of the child's U.S. citizenship, you may obtain a Certificate of Citizenship by filing BCIS form N-643 "Application for Certificate of Citizenship on Behalf of an Adopted Child" with the BCIS or apply for a passport with the State Department.

To obtain more information about California's Intercountry Adoption Program requirements, contact a private adoption agency licensed to provide these services in the county where you reside. Click here to obtain a " Directory of Public and Licensed California Adoption Agencies ".

15. How do I find an Adoption Service Provider?

An Adoption Service Provider (ASP) is a licensed private adoption agency or individual who advises a birth parent when the birth parent is considering the placement of their child for independent adoption unless the prospective adoptive parent is a grandparent, aunt, uncle, sibling, legal guardian who has been the child’s legal guardian for more than one year, or is a person named in the will of a deceased parent as an intended adoptive parent where the child has no other parent. For more information on ASPs, please visit the  Registry of California Adoption Services Providers website  or email:  [email protected] .

16. What is the Interstate Compact on the Placement of Children (ICPC)?

The ICPC is an agreement among the states to provide for movement of children across state boundaries for purposes of foster care or adoption.  The compact governs adoptive placements of children between states, including independent adoptions.  ICPC procedures must be followed and requirements met before children can be placed in another state.  There is more information on the ICPC website .

17. What is the difference between adoption and guardianship?

Adoption is the permanent legal assumption of all parental rights and responsibilities for a child.  Adoptive parents have the same legal rights and responsibilities as parents whose children are born to them.

Guardianship is a court-ordered relationship that gives an adult legal and physical custody of a child, with the right to make parental decisions about the child’s care and control, education, and medical treatment.  Guardianship does not terminate parental rights.

To learn more about probate guardianship, please review Information on Probate Guardianship of the Person (form GC-205-INFO) . To learn more about Kinship guardianship, please review the Kin-Gap Frequently Asked Questions pamphlet .

18. What is an Adoption Facilitator?

All adoption facilitators who were on the Adoption Facilitator Registry as of July 1, 2023 must cease operation by on or before December 31, 2023.  As of January 1, 2024, a person or entity operating or providing adoption facilitator services in California is prohibited.  Common practices and services undertaken by adoption facilitators:  arranging contact between birth parent(s) and prospective adoptive parents; advertising for the purpose of soliciting parties to an adoption; locating children for an adoption; acting as an intermediary between the parties to an adoption; and charging a fee or other valuable consideration for services rendered.  As of January 1, 2024, only authorized persons or organizations specified in Family Code Section 8609 may advertise in any periodical or newspaper, by radio, or other public medium, that he, she, or it will place children for adoption, or accept, supply, provide, or obtain children for adoption, or that causes any advertisement to be published in or by any public medium soliciting, requesting, or asking for any child or children for adoption is guilty of a misdemeanor.  Any person, other than a birth parent, or any organization, association, or corporation that, without holding a valid and unrevoked license to place children for adoption issued by the department, places any child for adoption is guilty of a misdemeanor.   As of January 1, 2024, Community Care Licensing (CCL) will investigate any complaint of entities or individuals providing adoption services defined in Health and Safety Code section 1502(a)(9) and (10) , except for those otherwise permitted by law to perform those functions.  To file a complaint, please visit the Complaint Hotline Page for contact information and more.

Quick Links

• Call 1(800) KIDS-4-US
• Directory of Public and Licensed California Adoption Agencies
• CDSS Adoptions Regional Offices
• Adoption Assistance Program
• Paid Family Leave for Adoptive or Foster Parents
• Registry of California Adoption Services Providers
• Can I get the federal Adoption Tax Credit?
• Information from AdoptUSKids.org

• Open access
• Published: 09 April 2024

Barriers and facilitators of implementation of new antibacterial technologies in patient care: an interview study with orthopedic healthcare professionals at a university hospital

• Lieve Vonken 1 ,
• Gert-Jan de Bruijn 2 ,
• Annika Noordink 1 ,
• Stef Kremers 1 &
• Francine Schneider 1  

BMC Health Services Research volume  24 , Article number:  447 ( 2024 ) Cite this article

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Metrics details

Antimicrobial resistance is a major global health threat. Therefore, promising new antibacterial technologies that could minimize our dependence on antibiotics should be widely adopted. This study aims to identify the barriers and facilitators of the adoption of new antibacterial technologies in hospital patient care.

Semi-structured interviews, based on the Consolidated Framework for Implementation Research, were conducted with healthcare professionals related to the orthopedics department of an academic hospital in The Netherlands.

In total, 11 healthcare professionals were interviewed. Scientific evidence for the effectiveness of the technology was the most explicitly mentioned facilitator of adoption, but other (often contextual) factors were also considered to be important. At the level of the inner and outer setting, high costs and lacking coverage, competition from other firms, and problems with ordering and availability were the most explicit perceived barriers to adoption. Participants did not collectively feel the need for new antibacterial technologies.

Conclusions

Barriers and facilitators of the adoption of new antibacterial technologies were identified related to the technology, the hospital, and external factors. The implementation climate might have an indirect influence on adoption. New antibacterial technologies that are scientifically proven effective, affordable, and easily obtainable will most likely be adopted.

Peer Review reports

The discovery of antibiotics prompted a revolution in treating bacterial infections and thereby medicine in general. Global dependence on antibiotics is currently high and increasing due to the high risk of infection in, for example, complex surgeries, treatment of chronic diseases, or chemotherapy [ 1 ]. However, the (inappropriate) use of antibiotics is rapidly fueling antimicrobial resistance (AMR) [ 1 ]. As bacteria become resistant to antibiotics, methods for preventing and treating infections become scarce since no simple alternatives to antibiotics exist [ 2 ]. This results in increased infection-related mortality and morbidity and will cause major losses in GDP (± 1%) and global trade [ 3 ]. The WHO, therefore, considers AMR to be one of the greatest threats to global health, food security, and development today [ 4 ].

In healthcare, AMR will challenge many procedures that rely on antibiotics for infection prevention such as surgeries and chemotherapy [ 3 ]. AMR is a major point of concern in orthopedics as the highly invasive surgeries and the use of prostheses result in high infection risk [ 5 ].

Infections strongly impact mortality and quality of life post-surgery. Specifically for prostheses, post-surgical infection at the implanted material surface is often considered the primary cause of implant failure [ 6 ]. For example, a Swedish study found that the mortality of total hip arthroplasty patients at 10 years was 14% higher in patients with prosthetic joint infections (48% versus 34%) [ 7 ]. To cope with the high infection risk, the need for antibiotics in orthopedics is especially high. With the rise of AMR, the burden of infections within orthopedics is expected to increase even further [ 5 ].

The imminent consequences of AMR stress the need for new antibacterial technologies that can help minimize our dependence on antibiotics. In recent years, promising technologies have been developed. These may be based on, for example, physicochemical methods and enable a reduction in the use of traditional antibiotics [ 2 ]. It is believed that the use of non-traditional antibacterial methods will prevent bacteria from obtaining resistance against these technologies [ 2 ]. Some examples of new antibacterial technologies are the coating of prostheses (with e.g., nanoparticles) and vaccination [ 2 ]. Many more technologies are now in the pipeline, most of which require different application methods than traditional antibiotics (e.g., the use of modified prostheses or the application of heat or ultrasound) [ 2 ].

To exploit the full potential of new antibacterial technologies they should be widely adopted in patient care without delay. However, we know from translational research that the widespread implementation of new technologies into clinical practice can take a long time [ 8 , 9 ]. The first major time lag in the implementation process takes place in the development of a product that can be used in the clinic [ 8 ]. Primarily, the duration of the introduction of new technologies in orthopedics is delayed by the high number of studies needed before a technology can be proven effective [ 10 ]. The second major lag is between the development of a clinically viable product and the implementation of this product in clinical practice [ 8 ]. This stage can be divided further, into the adoption and the implementation stage [ 11 ]. Adoption refers to the initiation of a new process and therefore is a prerequisite for implementation in every hospital.

Research shows that even effective technologies substantiated by evidence will not automatically be adopted in practice [ 12 ]. Additional barriers and facilitators of adoption have been identified for several medical technologies and include characteristics of the technology, the individuals involved, and the context in and around the hospital [ 9 , 13 ]. For technologies aimed at reducing antibiotic use, it can be argued that realizing changes is especially difficult since antibiotic use is embedded in structures (i.e., economic and political priorities), networks (i.e., communications), and practices (i.e., individuals) [ 14 ]. Knowledge about barriers and facilitators of adoption can be used to prepare and optimize the implementation process. However, these barriers and facilitators of adoption are not known for new antibacterial technologies.

The Consolidated Framework for Implementation Research (CFIR) provides a theoretical framework of potential barriers and facilitators of adoption and implementation at the external, internal, and individual levels, and related to the technology and the implementation process [ 15 ]. CFIR has been used to understand implementation and receptiveness to change in healthcare [ 16 , 17 ]. This study is theoretically based on CFIR and aims to provide insight into healthcare professionals’ perceptions about the adoption of new antibacterial technologies that do not apply traditional antibiotics. The research question is: What are the barriers and facilitators of the adoption of new antibacterial technologies in hospital patient care?

From February to April 2022, semi-structured individual interviews were conducted with healthcare professionals associated with the orthopedics department of the Maastricht University Medical Centre (MUMC+) in the Netherlands. The MUMC + is a university teaching hospital specializing in orthopedic infections, where patients with infections are referred from the periphery and a lot of research takes place. The study was approved by the Maastricht University Faculty of Health, Medicine and Life Sciences Research Ethics Committee (FHML-REC/2022/014). This report follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 18 ].

Participants and recruitment

Participants were identified through purposive and snowball sampling from January to April 2022. We purposefully started with a surgeon who plays a central role in local orthopedic infection prevention and control. After the first interview, all subsequent participants were invited based on snowball sampling through suggestions from other participants. At the end of each interview, participants were requested to suggest other individuals for participation in this study. The aim was to recruit a sample of key stakeholders who could all shed a different light on the research topic from a clinical perspective. After 11 interviews participants no longer suggested new and relevant participants. All participants were invited through an email containing information on the purpose of the study. After a positive response, an information document and an informed consent form were emailed.

The interviews took place face-to-face in the hospital or, upon participant request, online through Zoom (Maastricht University license). LV (MSc, PhD candidate, experience with interviews) conducted all interviews. At the start of each interview, the informed consent form was signed, and time was taken to get acquainted. All interviews were audio recorded and transcribed verbatim. Field notes were made to aid in transcribing if the recording was unclear. Participants did not receive transcripts or reports of findings.

Interviews were guided by a topic list. The topic list covered current infection-related practices and healthcare professionals’ attitudes towards AMR in general (the first part) and beliefs regarding barriers and facilitators of the adoption of new antibacterial technologies (the second part). Questions in the first part were inspired by two questionnaires on attitudes and beliefs about AMR [ 19 , 20 ]. The second part was based on CFIR and the topic list available from the CFIR website: https://cfirguide.org/ . The CFIR topic list was adapted to apply to the future implementation of a hypothetical product. First, the number of CFIR constructs was reduced to characteristics of the individual, the technology, the inner setting (i.e., the hospital), and the outer setting (i.e., outside of the hospital). Second, the questions were phrased more openly. To make the questions easier to answer, participants were asked to choose a procedure they often take part in and then, to imagine using a technological antimicrobial technology in this procedure that does not make use of traditional antibiotics. The theoretical basis of the topic list ensured that all relevant topics were discussed during the interview while the open-ended questions allowed for additional input from the participants. The topic list was piloted with two healthcare professionals to confirm this, resulting in minor changes in question phrasing. The topic list is available in the additional file (additional file 1 ).

A thematic analysis approach was taken, applying a hybrid design of inductive and deductive coding as described by Fereday and Muir-Cochrane [ 21 ]. A predefined coding tree was developed that followed the structure of the topic list and was based on the tools available on the CFIR website (see additional file 1 ). To test the reliability and finalize this predefined coding tree, LV and AN test-coded one interview. Then, the predefined coding tree was used by LV to code the remaining interviews. While coding, LV identified themes and developed the final coding tree by moving or adding (CFIR) constructs (see additional file 1 ). Following this, AN coded all interviews, including the one previously coded, using the final coding tree (weighed kappa 94.8%; unweighted kappa 94.7%). As the results presented below are based on the final coding tree, the data presented is consistent with the findings, and major as well as minor themes were described. Quotes with participant numbers were added to give body to the reoccurring themes.

Characteristics of the sample

Of the 10 healthcare professionals who were invited to participate, 9 participated. One invited participant proposed 2 more junior participants upon invitation instead of participating themselves. Thus, in total, 11 healthcare professionals participated: 4 surgeons (in training), 2 ward employees (nurse and nurse practitioner), 2 operating room (OR) employees (management and executive), and 3 infection (prevention) experts. The participants had an average of 11.3 years of experience in their profession (range: 1–30 years). All but one participant had daily to weekly encounters with patients with bacterial infections or antibiotic prescriptions. The participant who did not have such daily to weekly encounters is indirectly involved in these procedures and has a coordinating role. Previous participants suggested all but the first participants because they would have a role in the implementation of new technologies. On average, interviews lasted 40 min (range: 30–55 min).

Stakeholders involved in the adoption process

The most often mentioned relevant stakeholders were the surgeon, the department (chair), the purchasing department, the Board of Directors, OR planning and management, those responsible for sterility, OR material management, OR quality and safety officers, the infection prevention team, medical microbiologists, OR ICT and the microbiology lab. For all stakeholders, different barriers and facilitators would influence their attitude toward adopting new antibacterial technology.

”I think the surgeons will definitely be positive about this. With them, it won’t revolve around money. Neither in the OR. Maybe if it takes more OR time, that’s a different story of course. But in the end, the costs will be the most sensitive topic for the Board of Directors.” [D8] .

Technology-related barriers and facilitators

All participants stressed the need for scientific evidence before considering adopting new antibacterial technology. For a technology past the development phase, positive results from strongly regulated studies performed in the clinic, independent of industry, could facilitate adoption. Yet, for technologies that are still in the developmental phase, evidence of animal studies or a clear working mechanism could suffice as a facilitator. Participants explained that technology can be tested in a research context. In addition to scientific evidence, some participants indicated that positive information from peers or experts and a trustworthy and convincing industry representative would facilitate adoption.

“Hard evidence, of course, based on good studies. In a research center, you’re always at the beginning of the chain. So often you must proceed based on in-vitro data or material characteristics of which you suspect that they might have an effect.” [D1] .

All participants agreed that the technology itself would have to be effective and thereby benefit the patient. Moreover, cost-effectiveness was considered a facilitator, and high expenses were considered hindering. Implementing a very expensive technology was described as difficult. In addition, participants said user-friendliness would facilitate adoption. Some participants further indicated that it would facilitate adoption if the technology had an understandable working mechanism. Only one participant explicitly mentioned that adoption would be facilitated if the technology fits within the current treatment. This notion regarded the facilitating effect on adoption if a coating could be applied to all current implants.

Outer setting-related barriers and facilitators

Participants expected that the adoption of new antibacterial technology in a hospital would be influenced by (inter)national laws and regulations, peers, or patient associations. Explicitly mentioned barriers to adoption include the costs not being covered (e.g., developmental costs or reimbursement by health insurers), problems with ordering and availability of the technology, competition among firms, problems in collaborating with industry partners and legal rights to a technology, and lacking awareness among the general public and physicians. The technology being mentioned in national recommendations or guidelines was considered facilitating.

“If it works, it should end up in a guideline. If it doesn’t end up in a guideline, it’ll be very difficult to use it.” [D4] .

Patient-related barriers and facilitators of adoption

In all interviews, participants were asked about the patient as a potential barrier or facilitator to adoption. However, the patient was generally not perceived to influence adoption at all. Instead, the participants said to consider patients’ needs in their own adoption preferences. Participants explained that paternalism is preferred over shared decision-making once the technology is beyond the experimental stage. This is because the relevant information is believed to be overly complicated for patients. Only in the case of a new or experimental product will patients’ opinions be asked. Overall, participants expected that the patient would not object to a new procedure, especially if the procedure is explained well. However, some participants believed that patients might not be ready for something other than antibiotics, which could potentially be a barrier to adoption.

“Eventually they [patients] are referred to an expert center. And they expect expertise there. […] Deciding together is a hot topic, but you notice that patients are strongly influenced by what the expert suggests. […] Because it’s very specialized information.” [D2] .

Inner setting-related barriers and facilitators of adoption

Explicitly mentioned hospital-related barriers to adoption include high costs and current tenders and contracts with other suppliers. Less explicitly, momentary factors that influence the hospital’s priorities were mentioned as barriers to adoption (e.g., the implementation of care paths and one-stage revisions, COVID-19, and the consideration of environmental impact). Moreover, participants mentioned two factors that they felt could help facilitate the adoption process, though these are not prerequisites to adoption. First, current procedures for ordering and distributing materials and for measuring the resistance pattern in the lab would ideally fit with the new antibacterial technology. Second, education and training needed for use of the technology should be well-organized and should lead to new standard procedures. Some participants indicated that doctors should initiate this implementation process.

“Over the years I’ve seen quite a few changes. And it only makes your job more interesting. Because imagine that everything would stay the same, that would be boring. That’s what makes it so nice in a university hospital, new innovations, and something new every time.” [D11] .

Implementation climate

While this was not explicitly mentioned as a barrier or facilitator, the implementation climate of the hospital might also influence adoption. Primarily, if participants would perceive the priority of new antibacterial technology to be high, this might facilitate adoption. The perceived priority can be construed from three factors. Firstly, ideas about whether AMR is currently a problem that should be acted upon were mixed. While one half of the participants described AMR as a current problem, the other half explained that AMR is not urgent because the Netherlands is doing very well with regards to levels of AMR, or because AMR is a future as opposed to a current problem.

”When treating an infection, we do. But if you’re just placing a prosthesis […], then it [AMR] is not really considered.” [D7] .

Secondly, these divided opinions also showed when discussing the need for alternative antibacterial technologies. One half of the participants expressed the belief that these are very necessary right now while the other half believed that they should only be developed for future purposes. One participant did not recognize a current need for such technologies at all. Thirdly, while prevention and sterility in the OR and phage therapy were mentioned as alternative methods to curb AMR, no alternative methods were mentioned that would be prioritized over a new antimicrobial technology not making use of antibiotics. Overall, participants’ ideas about the priority of the new antibacterial technology were mixed. Merely the latter factor might be considered a facilitator.

”I always say: “Show me the money”. What does it do? How does it work? How effective is it? What’s the science behind it? What’s known about the working mechanism, about resistance, about effectiveness, about the duration of the effect? What’s known about the micro-organisms etcetera.” [D6] .

In addition, another aspect of the implementation climate, innovation-readiness, might facilitate adoption in this hospital, even though that facilitating effect was not explicitly mentioned. The positive influence of innovation-readiness on adoption can also be construed from three factors. Firstly, half of the participants mentioned that the hospital in which they work is always looking for ways to improve their care. While some participants indicated that adjustments occur frequently and smoothly (e.g., reconstruction, training of staff), others indicated that making changes to standard practice is difficult.

“What of course plays a very important role here is that this is a center of expertise for infections. That is one of the focal points. […] If you can accomplish improvement there, then that will definitely be high on the list of priorities.”[D8] .

Secondly, all participants who indicated that they would have a role in adoption described themselves as initiators or early adopters of change and very open to new antibacterial technologies. Thirdly, all but one participant could mention new examples of such technologies and felt capable to work with them in the future. Coatings, bioactive glass, and phage therapy were mentioned most often.

“I won’t be the very first, but maybe within the first 10–15%. If I stand for it being good.” [D9] .

This study was aimed at providing insight into barriers and facilitators of adopting new antibacterial technologies in patient care as perceived by hospital healthcare professionals. We interviewed a variety of clinical healthcare professionals who would be involved in adopting such technologies in the field of orthopedics. Expected barriers and facilitators of adoption were based on characteristics of the technology, the inner hospital setting, and the outer setting. Moreover, participants shared personal perceptions related to the implementation climate of the hospital that might underlie the barriers and facilitators mentioned.

At the level of the technology, its usability and the availability of scientific evidence of its effectiveness were considered to facilitate successful adoption. The need for scientific evidence that proves effectiveness is supported by a recent systematic review into barriers to the diffusion of medical innovations in healthcare [ 9 ]. In this study, it is described that the lack of high-quality evidence can hamper adequate adoption decisions [ 9 ]. Especially in orthopedics, scientific evidence is valued highly. This is partly because well-known orthopedic failures in recent years have highlighted the need for good evidence [ 10 ]. With regard to usability, participants described that if technology would allow for measuring the resistance pattern this would be facilitating. User-friendliness was also deemed important while problems with ordering, availability, and distribution of the technology were listed as potential barriers. Interestingly, these more practical barriers and facilitators of adoption were not identified in the aforementioned systematic review [ 9 ]. Participants may have mentioned these practical factors as a result of the timing of our study. Since the technologies are not yet developed, the innovation was described without details. Participants thus may have listed barriers and facilitators that prove not to be applicable to most technologies.

An important hindering factor was mentioned at the contextual levels of the inner hospital setting and outer setting. Specifically, lacking financial arrangements were listed as a potential barrier to adoption. Many previous studies have also described the importance of appropriate financial structures [ 9 ]. Participants of this study additionally described that competing (currently used) technologies complicated financing the adoption of new antibacterial technologies. Furthermore, it would facilitate adoption if national recommendations or guidelines would be issued that include the technology, according to the participants. The importance of guidelines was also highlighted in previous research [ 22 ].

Previous studies have recognized the patient as influential in adoption [ 13 , 22 ]. Specifically, characteristics of the patient and their disease might facilitate or hamper the application of new innovations, or the patient themselves might be an actor in the decision-making process [ 13 , 22 ]. Though the clinicians in this study said to have the patients’ best interests at heart, they generally did not mention the patient or their opinions as a barrier or facilitator to adoption. The complicated nature of the infection treatment was listed as a reason for not asking for patient preferences. Not knowing the patients’ preferences meant these preferences would not influence adoption. This seems contradictory to other studies in which the patient’s role in the decision-making process was described as ‘very active’ [ 22 ]. However, ‘very active’ patients were also described as ‘well informed’ [ 22 ], something that is, according to our participants, difficult for orthopedic infections. Earlier research also found that in general, some physicians might not be willing to consider patient preferences [ 13 ].

Next to the explicitly mentioned barriers and facilitators of adoption, questions related to the CFIR implementation climate revealed more implicit factors that might influence adoption. One remarkable perception that was identified in this study relates to the perceived priority of the new antibacterial technology. Most interestingly, participants were divided about whether AMR is currently an urgent problem that demands action. Some participants explained their sense of urgency was low because AMR is a problem for the future or in other countries besides the Netherlands. The dividedness about the urgency of AMR is in agreement with a recent study among infection control specialists where only about half of the Dutch participants perceived the risk of AMR to be high [ 23 ]. Further, an explanation for the low urgency these healthcare professionals perceive is related to the conclusion of systematic reviews of studies about healthcare professionals’ knowledge and beliefs about AMR. These described that clinicians often perceive AMR to be a problem “not in my backyard” [ 24 , 25 ]. In other words, the perceived severity of AMR may be high but their perceived susceptibility is low. This also applies to the participants in our study who, for example, described that AMR is not a problem in The Netherlands. We know from behavior change theories that if the perceived risk (i.e., perceived severity and/or susceptibility) is low, the tendency for acting against that risk is often low as well [ 26 ]. Therefore, increasing our participants’ perceived AMR urgency and priority of the new antibacterial technologies might be a prerequisite for their willingness to adopt them.

Another remarkable characteristic of the participants of this study was their innovation-readiness. Although this was not explicitly mentioned as a facilitator of adoption it might indirectly facilitate the adoption process. Participants described themselves as innovative and adopting new antibacterial technology was not met with hesitance. Furthermore, they described their academic hospital as a setting where change and innovation occur often. These results fit with the idea that innovation is one of the purposes of an academic hospital [ 27 ]. Following Roger’s Diffusion of Innovations Theory, such an innovative group of healthcare professionals could play an important role in the adoption of new antibacterial technologies by kickstarting the adoption process [ 28 ]. However, since innovation-readiness was not explicitly mentioned as a facilitator to adoption it is unclear whether this might indeed lead our participants to kickstart adoption. We cannot conclude that all participants will automatically be innovators. For example, it has been shown that a hospital’s academic status does not guarantee innovation [ 27 ].

Strengths and limitations

The main strength of this study is the structured and theoretical approach based on CFIR, an established implementation framework [ 15 ]. This approach yielded an extensive list of potential barriers and facilitators of the adoption of new antibacterial technology which allowed us to ask for a broad spectrum of possible barriers and facilitators. A further strength is that we interviewed healthcare professionals in different professions who shed different lights on our topic, again resulting in a broad spectrum of possible barriers and facilitators.

A limitation of this study is that we could only describe a hypothetical product without details on the product level since the technologies of interest are currently still under development. This required stakeholders to imagine a product and its implementation. Some implementation problems might only become evident to participants once a product’s characteristics are described. Especially the technology-related barriers and facilitators are dependent on specific technology characteristics.

A further limitation is that, while the sample of key stakeholders was diverse, we only interviewed clinical healthcare professionals who were suggested by previous participants. Firstly, we did not verify the amount of decision power participants had. Secondly, stakeholders responsible for the barriers and facilitators identified (i.e., the Board of Directors, insurers, and guideline developers) might help to further understand the context influencing these barriers and facilitators. Thirdly, the diversity of the participants (e.g., in years of experience) and the small sample size did not allow for the extensive identification of differences between different types of healthcare professionals. Lastly, further research should explore the patient’s perspective.

Recommendations

When implementing new technologies in practice, it is often recommended to focus on the development of a large evidence base for the effectiveness and safety of these technologies [ 10 ]. However, this study shows that although orthopedic healthcare professionals in an academic hospital perceive evidence as an important facilitator for the adoption of antibacterial technologies, other barriers and facilitators might also influence the adoption success. We recommend both researchers and technology developers study barriers and facilitators of the adoption of their technology early in the development process. At an earlier stage, adaptations to the technology or the implementation setting are often more feasible. For example, the technology could be designed with easy distribution and ordering in mind.

For future research, we recommend two types of studies. First, the association between adoption and the identified barriers and facilitators should be confirmed in further research. Specifically, quantitative studies describing the strength of the association should be performed. Second, when approaching the adoption of a specific technology, we recommend repeating the current study, though focusing more on the characteristics of the technology and interviewing more stakeholders (e.g., the Board of Directors). Academic specialized hospitals might be the starting point in such research as these centers are familiar with innovation and research and might therefore be more open to innovation. Additional studies are needed to be able to guide the implementation of antibacterial technologies in (peripheral) hospitals where innovation, participation in research, and new orthopedic technologies are less common. In these hospitals, other factors might influence the adoption of new antibacterial technology.

In this study, in a sample of orthopedic healthcare professionals from an academic hospital, barriers and facilitators of the adoption of new antibacterial technologies were identified related to the technology, the hospital, and external factors. The results suggest that the adoption of new antibacterial technology in orthopedics is easiest if the technology is scientifically proven effective and if barriers related to the hospital and external factors can be overcome. However, the adoption of new antibacterial technologies in an academic-specialized hospital could also be influenced by the implementation climate. Specifically, a lack of perceived priority for new antibacterial technologies might hinder adoption while the innovation-readiness of the hospital and the staff might facilitate adoption. Adoption strategies should be tailored to the innovation-readiness of the hospital and the priority given to new antibacterial technologies. Developers and implementers of new antibacterial technologies for orthopedics should focus particularly on developing new antibacterial technologies that are scientifically proven effective, affordable, and easily obtainable.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to them containing information that could compromise research participant privacy but are available from the corresponding author in anonymized form on reasonable request.

Abbreviations

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Consolidated Framework for Implementation Research

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Vonken, L., de Bruijn, GJ., Noordink, A. et al. Barriers and facilitators of implementation of new antibacterial technologies in patient care: an interview study with orthopedic healthcare professionals at a university hospital. BMC Health Serv Res 24 , 447 (2024). https://doi.org/10.1186/s12913-024-10878-4

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Toward a framework for selecting indicators of measuring sustainability and circular economy in the agri-food sector: a systematic literature review

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The implementation of sustainability and circular economy (CE) models in agri-food production can promote resource efficiency, reduce environmental burdens, and ensure improved and socially responsible systems. In this context, indicators for the measurement of sustainability play a crucial role. Indicators can measure CE strategies aimed to preserve functions, products, components, materials, or embodied energy. Although there is broad literature describing sustainability and CE indicators, no study offers such a comprehensive framework of indicators for measuring sustainability and CE in the agri-food sector.

Starting from this central research gap, a systematic literature review has been developed to measure the sustainability in the agri-food sector and, based on these findings, to understand how indicators are used and for which specific purposes.

The analysis of the results allowed us to classify the sample of articles in three main clusters (“Assessment-LCA,” “Best practice,” and “Decision-making”) and has shown increasing attention to the three pillars of sustainability (triple bottom line). In this context, an integrated approach of indicators (environmental, social, and economic) offers the best solution to ensure an easier transition to sustainability.

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The sample analysis facilitated the identification of new categories of impact that deserve attention, such as the cooperation among stakeholders in the supply chain and eco-innovation.

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Source: Authors’ elaboration. Notes: The graph shows the temporal distribution of the articles under analysis

Source: Authors’ elaborations. Notes: The graph shows the time distribution of articles from the three major journals

Source: Authors’ elaboration. Notes: The graph shows the composition of the sample according to the three clusters identified by the analysis

Source: Authors’ elaboration. Notes: The graph shows the distribution of articles over time by cluster

Source: Authors’ elaboration. Notes: The graph shows the network visualization

Source: Authors’ elaboration. Notes: The graph shows the overlay visualization

Source: Authors’ elaboration. Notes: The graph shows the classification of articles by scientific field

Source: Authors’ elaboration. Notes: Article classification based on their cluster to which they belong and scientific field

Source: Authors’ elaboration

Source: Authors’ elaboration. Notes: The graph shows the distribution of items over time based on TBL

Source: Authors’ elaboration. Notes: The graph shows the Pareto diagram highlighting the most used indicators in literature for measuring sustainability in the agri-food sector

Source: Authors’ elaboration. Notes: The graph shows the distribution over time of articles divided into conceptual and empirical

Source: Authors’ elaboration. Notes: The graph shows the classification of articles, divided into conceptual and empirical, in-depth analysis

Source: Authors’ elaboration. Notes: The graph shows the geographical distribution of the authors

Source: Authors’ elaboration. Notes: The graph shows the distribution of authors according to the continent from which they originate

Source: Authors’ elaboration. Notes: The graph shows the time distribution of publication of authors according to the continent from which they originate

Source: Authors’ elaboration. Notes: Sustainability measurement indicators and impact categories of LCA, S-LCA, and LCC tools should be integrated in order to provide stakeholders with best practices as guidelines and tools to support both decision-making and measurement, according to the circular economy approach

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Silvestri, C., Silvestri, L., Piccarozzi, M. et al. Toward a framework for selecting indicators of measuring sustainability and circular economy in the agri-food sector: a systematic literature review. Int J Life Cycle Assess (2022). https://doi.org/10.1007/s11367-022-02032-1

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UC Berkeley study confirms that yes, EVs do what they promise to do

A new study from UC Berkeley confirms what EV fans already know: EV adoption does, in fact, make the air cleaner. Perhaps even more importantly, the study offers some quantifiable, granular data about how much electric vehicles are impacting emission rates in the here and now, not just in the foreseeable future.

Not that these numbers will blow you away, mind you, but still, it’s good news. Researchers from the University of California, Berkeley , found that between 2018 and 2022, CO2 emission from all sources (industries, homes, traffic) across the San Francisco Bay Area dropped around 1.8% per year – a difference the researchers attribute to widespread EV adoption in the area. For vehicle emission rates, those numbers dropped 2.6% annually. EVs made up nearly 40% of new auto registrations in San Jose and 34% in San Francisco last year.

“We show from atmospheric measurements that adoption of electric vehicles is working, that it’s having the intended effect on CO 2  emissions,” said Ronald Cohen, a University of California Berkeley chemistry professor and senior author of the study. The study was published this week in the journal Environmental Science & Technology.

Researchers were able to track that data via a network of sensors around the Bay Area that monitor both CO2 and five critical air pollutants: carbon monoxide, nitrous oxides (NO and NO 2 ), ozone, and particulates (PM 2.5).  

Top comment by Henry Ng

In ten years time, we in the Bay Area will see the direct results of EV by simply counting the number of spare-the-air days per year, and people with respiratory issues will have fewer concerns to worry about.

According to the research, by comparing the air pollution and CO2 data, the sensors help determine the emission source. The sensors are also unique in that they track CO2, which is not a pollutant regulated by the Clean Air Act and not picked up by Environmental Protection Agency sensors – the EPA of course does track CO2 but not as an air pollutant.

To get to their results, the researchers divided the emissions captured by the sensors into three categories: industry, such as refineries, which churn out a steady stream of emissions; seasonable varying emissions, like home heating and cooling; and traffic. After isolating the traffic emissions , researchers were able to link a dip traffic emissions to the rise in EVs, hybrids, and vehicles with better fuel efficiency. While the sensors have been in place for more than a decade, it’s taken time to analyze the findings – and one could argue a while for EVs to reach a critical mass to trigger a difference. Looking at the data, the researchers also saw a drop in emissions during the pandemic. The network of 50 sensors, set up in 2012 by Cohen, make up what’s called the  Berkeley Environmental Air Quality & CO2 Network  (BEACO2N), a system that has already been adopted by Providence, Rhode Island, and Glasgow, Scotland, to track their city air pollution. Around 70% of global CO2 emissions come from cities, yet few urban areas have granular data about where those emissions originate.

Another study last year, published by Keck School of Medicine at the University of Southern California, found similar results looking at emissions in California . That study tracked real-world pollution levels, electric car penetration, and emergency room visits across California between 2013 and 2019, and controlled against overall improvements in California air quality during the study period.

Electrek’s Take

Of course, any optimism is tempered by the reality that, to meet California and Bay Area carbon reduction goals, the yearly decrease needs to be much greater – twice what it is now. California has a goal to reach net-zero emissions by 2045, and Cohen says that we need emissions to drop 3.7% per year to reach that. Still, the onus isn’t only on traffic emissions. Home and industry emissions need to drop too, and making that happen requires policies .

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Jennifer is a writer and editor for Electrek. Based in France, she has worked previously at Wired, Fast Company, and Agence France-Presse. Send comments, suggestions, or tips her way via X (@JMossalgue) or at [email protected].

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Understanding adoption: A developmental approach

As children grow up, they develop a positive sense of their identity, a sense of psychosocial well-being ( 1 ). They gradually develop a self-concept (how they see themselves) and self-esteem (how much they like what they see) ( 2 ). Ultimately, they learn to be comfortable with themselves. Adoption may make normal childhood issues of attachment, loss and self-image ( 2 ) even more complex. Adopted children must come to terms with and integrate both their birth and adoptive families.

Children who were adopted as infants are affected by the adoption throughout their lives. Children adopted later in life come to understand adoption during a different developmental stage. Those who have experienced trauma or neglect may remember such experiences, which further complicates their self-image ( 1 ). Transracial, crosscultural and special needs issues may also affect a child’s adoption experience ( 2 , 3 ). All adopted children grieve the loss of their biological family, their heritage and their culture to some extent ( 4 ). Adoptive parents can facilitate and assist this natural grieving process by being comfortable with using adoption language (eg, birth parents and birth family) and discussing adoption issues ( 5 ).

The present statement reviews how children gain an understanding of adoption as they grow from infancy through adolescence. Specific issues relevant to transracial adoptions are beyond the scope of this statement and will not be addressed.

INFANCY AND EARLY CHILDHOOD

During infancy and early childhood, a child attaches to and bonds with the primary care-giver. Prenatal issues, such as the length of gestation, the mother’s use of drugs or alcohol, and genetic vulnerabilities, may, ultimately, affect a child’s ability to adjust. The temperament of everyone involved also plays a role.

As a child approaches preschool age, he or she develops magical thinking, that is, the world of fantasy is used to explain that which he or she cannot comprehend. The child does not understand reproduction, and must first understand that he or she had a birth mother and was born the same way as other children ( 2 , 5 ). Even though a child as young as three years of age may repeat his or her adoption story, the child does not comprehend it ( 3 , 5 ). The child must first grasp the concept of time and space, which usually occurs at age four to five years, to see that some events occurred in the past, even though he or she does not remember them. The child must understand that places and people exist outside of his or her immediate environment.

Telling a child his or her adoption story at this early age may help parents to become comfortable with the language of adoption and the child’s birth story. Children need to know that they were adopted. Parents’ openness and degree of comfort create an environment that is conducive to a child asking questions about his or her adoption ( 3 ).

SCHOOL-AGED CHILDREN

Operational thinking, causality and logical planning begin to emerge in the school-aged child. The child is trying to understand and to master the world in which he or she lives. The child is a problem solver. He or she realizes that most other children are living with at least one other biological relative ( 6 ). It is the first time that the child sees himself or herself as being different from other children. The child may struggle with the meaning of being adopted, and may experience feelings of loss and sadness ( 1 , 7 ). He or she begins to see the flip side of the adoption story and may wonder what was wrong with him or her; why did the birth mother place him or her up for adoption? The child may feel abandoned and angry ( 1 , 2 ). It is normal to see aggression, angry behaviour, withdrawal or sadness and self-image problems ( 1 , 8 ) among adopted children at this age. The child attempts to reformulate the parts of his or her story that are hard to understand and to compensate for emotions that are painful ( 2 ). As a result, daydreaming is very common among adopted children who are working through complex identity issues ( 5 , 7 ).

Control may be an issue. A child may believe that he or she has had no control over losing one family and being placed with another. The child may need to have reassurance about day to day activities or may require repeated explanations about simple changes in the family’s routine ( 5 ). Transitions may be particularly difficult. The child may have an outright fear of abandonment, difficulty falling asleep and, even, kidnapping nightmares ( 1 ).

It is helpful to explain that the birth mother made a loving choice by placing the child up for adoption, that she had a plan for his or her future. The child may need to hear this statement repeatedly. There is some similarity between the symptoms of grief and symptoms associated with attention deficit/hyperactivity disorder; care givers must be wary not to label a child with attention deficit/hyperactivity disorder when, in fact, the child’s behaviour is consistent with a normal grieving process ( 9 ). A parent’s patience and understanding are crucial at this point of an adopted child’s life. Parents may be pro-active by educating school personnel about the natural grieving issues related to adoption that their child is experiencing.

ADOLESCENCE

The adolescent’s primary developmental task is to establish an identity while actively seeking independence and separation from family ( 2 ). The adopted adolescent needs to make sense of both sets of parents, and this may cause a sense of divided loyalties and conflict ( 7 ). In early adolescence, the loss of childhood itself is a significant issue. The adopted adolescent has already experienced loss, making the transition to adolescence even more complicated ( 1 , 7 ). This period of development may be difficult and confusing. Adolescents may experience shame and loss of self-esteem, particularly because society’s image of birth parents is often negative ( 2 ).

Adopted adolescents will want to know details about their genetic history and how they are unique. They will reflect on themselves and their adoptive family to determine similarities and differences. They will attempt to ascertain where they belong and where they came from ( 7 ). All adolescents may have a natural reticence about talking to their parents, and adopted adolescents may not share questions about their origins with their parents. They may keep their reflections to themselves. Adopted adolescents’ search for information about themselves is very normal, and parents should not see this as a threat. Instead, parents’ willingness to accept their child’s dual heritage of biology and environment will help their child to accept that reality ( 7 ).

CONCLUSIONS

Children’s interest in adoption varies throughout the developmental stages of childhood and adolescence. As children progress from one stage to another, they gain new cognitive abilities and psychosocial structures. They look at adoption differently and, often, have more concerns or questions. Their questions may diminish until a new cognitive and psychosocial level is reached. Parents can facilitate this developmental process by being knowledgeable and supportive, and by continuing to retell their child his or her adoption story. The grief that their child experiences is real and should not be denied or avoided. Support from knowledgeable health care providers is invaluable in helping adoptive parents and their child. Although this statement has addressed common issues that relate to a child’s perception of adoption, a psychological or psychiatric referral is indicated if the child suffers from depression, or has symptoms that affect his or her day-to-day functioning. Paediatricians and other professionals who care for children should provide anticipatory guidance by counselling parents of adopted children about relevant issues that concern their child’s understanding of his or her adoption.

Good, common sense resources are available to parents. Lois Melina’s Making Sense of Adoption: A Parent’s Guide ( 5 ) is an excellent, practical source of adoption information for parents. Joyce Maguire Pavao’s The Family of Adoption ( 7 ) looks at the entire family’s adoption experience throughout the family life cycle. Also, “Talking to children about their adoption: When to start, what to say, what to expect”, is a brief, yet informative, article for parents that was published in the Adopted Child newsletter ( 6 ).

COMMUNITY PAEDIATRICS COMMITTEE

Members: Drs Cecilia Baxter, Edmonton, Alberta; Fabian P Gorodzinsky, London, Ontario; Denis Leduc, Montréal, Québec (chair); Paul Munk, Toronto, Ontario (director responsible); Peter Noonan, Charlottetown, Prince Edward Island; Sandra Woods, Val-d’Or, Québec;

Consultant: Dr Linda Spigelblatt, Montréal, Québec

Liaison: Dr Joseph Telch, Unionville, Ontario (Canadian Paediatric Society, Community Paediatrics Section)

Principal author : Dr Cecilia Baxter, Edmonton, Alberta

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

ORIGINAL RESEARCH article

Spatial modeling of land resources and constraints to guide urban development in saudi arabia's neom region provisionally accepted.

• 1 Geography Department, College of Arts, Princess Nourah bint Abdulrahman University, Saudi Arabia
• 2 Water Resources Research Institute, National Water Research Center (NWRC), Egypt
• 3 Department of Geography and Urban Planning, College of Humanities and Social Sciences, United Arab Emirates University, United Arab Emirates
• 4 Urban Planning Department, Environmental Studies and Land Use Division, National Authority for Remote Sensing and Space Sciences, Egypt
• 5 Water Resources and Stormwater, Other, Lebanon

The final, formatted version of the article will be published soon.

This research presents a GIS-based approach to evaluate land suitability for the urbanization of Saudi Arabia's NEOM region, an ambitious initiative for sustainable development within a desert setting. By employing a multi-criteria decision-making framework, we have synthesized data on land resources, stability, accessibility, construction costs, and proximity to conservation areas using the Analytical Hierarchy Process (AHP) to prioritize these factors based on their importance for sustainable growth.Our analysis reveals that areas designated with grid values of 9 and 8, totaling 6312.33 square kilometers or 28.23% of the area studied, are most favorable for urban development. These sectors span the northern, central, and southern parts of NEOM, notable for their strategic location near future infrastructure and natural assets conducive to sustainable practices. This finding supports NEOM's key initiatives like "The Line," "Oxagon," and "TROJENA," showcasing the model's utility in directing urban development strategies.The paper discusses the broader socioeconomic and environmental ramifications of pinpointing areas suited and unsuited for development, underlining the model's role in facilitating decision-making that aligns urban expansion with environmental stewardship. Furthermore, it advocates for leveraging development-restricted zones in conservation efforts and renewable energy ventures.Nevertheless, the study concedes certain limitations, such as the dependence on static datasets and inherent challenges related to the AHP method, including the presumption of criteria independence. Future research avenues are proposed, emphasizing the integration of dynamic data sources, comprehensive socio-cultural impact evaluations, and the adoption of flexible urban planning methodologies to refine the model's precision and practicality. Overall, this detailed examination showcases NEOM's blueprint as an exemplar for future urban environments, illustrating a systematic strategy for developing desert regions that integrate innovation, ecological sustainability, and the preservation of cultural heritage.

Keywords: Site suitability evaluation, Geographic information system (GIS), remote sensing, Analytic Hierarchy Process (AHP); Sustainability, urban development, NEOM

Received: 15 Jan 2024; Accepted: 08 Apr 2024.

Copyright: © 2024 Alogayell, Kamal, Alkadi, Ramadan, Ramadan and Zeidan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Mona S. Ramadan, Department of Geography and Urban Planning, College of Humanities and Social Sciences, United Arab Emirates University, Al Ain, United Arab Emirates

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California spent billions on homelessness without tracking if it worked

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California has failed to adequately monitor the outcomes of its vast spending on homelessness programs, according to a state audit released Tuesday, raising questions about whether billions of dollars meant to thwart the crisis has been worth it as the number of people living unsheltered has soared.

A new report from the California State Auditor’s Office found that a state council created to oversee the implementation of homelessness programs has not consistently tracked spending or the outcomes of those programs.

That dearth of information means the state lacks pertinent data and that policymakers “are likely to struggle to understand homelessness programs’ ongoing costs and achieved outcomes,” the audit says.

“The state must do more to assess the cost-effectiveness of its homelessness programs,” California State Auditor Grant Parks said in a letter sent to Gov. Gavin Newsom and state lawmakers Tuesday accompanying the audit.

California has spent $20 billion over the past five years dedicated to the state’s homelessness crisis, including funneling money toward supporting shelters and subsidizing rent. Still, homelessness grew 6% in 2023 from the year prior, to more than 180,000 people, according to federal “point in time” data. Since 2013, homelessness has grown in California by 53%.

The California Interagency Council on Homelessness — created in 2016 to oversee the state’s implementation of programs dedicated to the worsening crisis — has not ensured the accuracy of the information in a state data system and has not evaluated homelessness programs’ success, according to the state auditor.

The audit recommends that the state Legislature require that the council report spending plans and outcomes of state funded homelessness programs annually and to make that information public. It recommends a type of “scorecard” to track the success of programs.

The council consists of state officials including Health and Human Services Secretary Dr. Mark Ghaly and California Department of Corrections and Rehabilitation Secretary Jeff Macomber.

The governor’s office referred questions about the audit to the California Business, Consumer Services and Housing Agency, which cited a law Newsom signed in 2021 that requires entities receiving state homeless funds to collect data. Since the law took effect last year, the California Interagency Council on Homelessness has made “significant progress,” spokesperson Russ Heimerich said in an email.

“The State Auditor’s findings highlight the significant progress made in recent years to address homelessness at the state level, including the completion of a statewide assessment of homelessness programs. But it also underscores a need to continue to hold local governments accountable, who are primarily responsible for implementing these programs and collecting data on outcomes that the state can use to evaluate program effectiveness,” he wrote on behalf of the California Interagency Council on Homelessness.

The response echoes frustrations among state and local leaders over which level of government is responsible for solving California’s homeless problem. In 2022, Newsom got tough on mayors when he rejected every local homeless action plan in the state , deeming them not ambitious enough.

Out of five state programs analyzed, auditors found that two were likely cost effective: Project Homekey — Newsom’s COVID driven project to convert hotels into housing — and the CalWORKs Housing Support Program, which offers financial assistance and other services to low income residents. The others analyzed, including a state rental assistance program, could not be reviewed because “the state has not collected sufficient data on the outcomes of these programs,” according to auditors.

“Collecting and reporting all state homelessness programs’ financial data allows for more complete and timely information about the state’s overall spending on homelessness. It also makes possible greater coordination of homelessness programs’ funding and may enable cost‑effectiveness comparisons,” the audit stated.

Based on the data available, the audit also revealed that most people involved in state programs are placed into interim housing such as shelters and do not end up in permanent housing.

A bipartisan group of lawmakers including state Sen. Dave Cortese (D-San Jose) and Assemblyman Josh Hoover (R-Folsom) requested that the Joint Legislative Audit Committee authorize a state audit of the efficacy of state homeless funding last year as California’s unhoused population — the nation’s largest — has continued to grow despite record state funding invested to combat it.

“The biggest conclusion that the auditors came back with is there’s just inadequate transparency and data and information available,” Cortese told reporters in Sacramento on Tuesday.

Cortese said the audit will act as a blueprint for the Legislature to consider stricter reporting on homelessness spending in the future and said it should not deter the state from funding homelessness responses.

“I think our constituents want us to continue to invest, and I think our constituents are going to want us to continue to audit the effectiveness of our efforts,” he said. “I don’t think it’s a time to stop.”

State Republicans chastised the Newsom administration for the lack of data and said it’s proof that Democrat-backed strategies are not working as the state grapples with a multibillion-dollar budget deficit.

“California is facing a concerning paradox: despite an exorbitant amount of dollars spent, the state’s homeless population is not slowing down,” Sen. Roger Niello (R-Roseville) said in a statement. “These audit results are a wake-up call for a shift toward solutions that prioritize self-sufficiency and cost effectiveness.”

Assemblymember Gregg Hart (D-Santa Barbara), chair of the Joint Legislative Audit Committee, said Tuesday he plans to conduct an oversight hearing to “further investigate” the audit results.

Tuesday’s audit comes just weeks after voters approved Proposition 1 , Newsom’s $6.4-billion bond measure that aims to address one aspect of homelessness by building more treatment facilities for people who have problems with drug addiction or mental illness.

Another part of the audit examined spending by the cities of San José and San Diego, which have both struggled to help unhoused residents. The audit found that neither of those cities have “evaluated the effectiveness” of their programs despite millions in funding to respond to homelessness.

“San José and San Diego identified hundreds of millions of dollars in spending of federal, state, and local funding in recent years to respond to the homelessness crisis. However, neither city could definitively identify all its revenues and expenditures related to its homelessness efforts because neither has an established mechanism, such as a spending plan, to track and report its spending,” the audit states. “The absence of such a mechanism limits the transparency and accountability of the cities’ uses of funding to address homelessness.”

Cortese — whose Silicon Valley district has long been home to some of the nation’s largest homelessness encampments , a stark juxtaposition against the backdrop of stunning wealth — said the findings regarding the two major cities could be a harbinger for future data discoveries.

“If those two cities are experiencing issues or if there’s symptoms of challenges that we need to correct, that probably exists in many, many other cities in the state of California,” he said.

More to Read

L.A. agrees to pay up to $2.2 million for outside audit of homelessness programs

April 6, 2024

A federal judge orders a sweeping outside audit of L.A. homelessness programs

March 22, 2024

Opinion: Californians narrowly passed Proposition 1. Can the state ensure the measure will work?

March 21, 2024

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Mackenzie Mays covers state government and politics in the Los Angeles Times’ Sacramento bureau. Previously, she worked as an investigative reporter for Politico, the Fresno Bee and the Charleston Gazette-Mail. In 2019, she received the National Press Club Press Freedom Award for her political watchdog reporting. She is a graduate of West Virginia University and proud Appalachian.

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