07-v2n2-3735-articles

ORIGINAL ARTICLES

 

Children living on the street


Patricia J. Kelly1, Bettina Grajcer2, Fatima Dinis Rigato2

1University of Texas Health Science Center at San Antonio
2São Paulo Federal University  

 


ABSTRACT
Children who spend part or all of their developmental years living on the streets constitute a vulnerable population. Local and national governments are in great need of research-based programs to supplement their efforts at providing health and social services. This article provides a review of what is known about children living on the street, describes a Sao Paulo program that works with this population, and makes suggestions for research that nurses might undertake.
Descriptors: Street children, Vulnerable populations, Literature review.



PROBLEM STATEMENT

Programs that provide concrete social and health services to children and adolescents are urgently needed in communities where youth without traditional homes and support systems congregate.

Whether this population is characterized as “homeless”, “runaway”, or “street” children, whether in urban centers like Recife, Brazil, academic communities like Austin, U.S., or smaller towns in the mountains of Bulgaria, adolescents use the streets to live, play, sleep, and earn a living (Aneci, Borba, & Ebrahim, 1992; Barrett, 1999; Rew, Fouladi, & Yockey, 2002). While social and cultural differences exist among the many streets in which children live, poverty, violence, and exploitation are common links in their lives.

The sheer numbers of young people living formally and informally on the streets throughout the world is daunting. UNICEF estimates that there are 100 million children who live on the street either all or part of the year. These numbers include 10,000 girls on the streets of Dhaka, Bangladesh, 240,000 abandoned children in Mexico City, 5-10,000 in Phnom Penh, Cambodia, and 50-70,000 in Manilla, Phillipines. While the magnitude of the problem tends to be greater in less developed countries, there are still 7,000 street children in the Netherlands, 4,000 in Belgium, and 10,000 in France.

The United States has about 500,000 under-age runaways and “throw-away” children (http://www.inministrytochildren. org/facts/stats.html). Reliable accounts from Brazil suggest that between 7 and 8 million children aged 5 to 18 live or work on the streets of urban Brazil (Barker, 1992). In the São Paulo metropolitan region, there are an estimated 200,000 children who do not live with their families (Ribeiro & Trench Ciampone, 2001).

Whether we apply a simple standard of social justice or an international agreement such as the United Nations Convention on the Rights of the Child, the poverty, abuse, and neglect to which these children are subjected constitute a clear violation of their human rights (Ehiemere, 2000). Without access to services that can address basic needs such as food, shelter, education, and access to health care, these children have the most minimal opportunities to access their potential and become fully functioning adults (Figueiras, 1992; Inciardi & Surratt, 1998). They are unsupervised and unprotected, with substance abuse, HIV risks, and violence are common at home, school, and on the streets (Anarfi, J., 1997; Noto, et al., 1997; Ramphele, 1997). The 1989 convention on the Rights of the Child clearly states that children are a vulnerable group that deserves the protection of society. Children also merit professional attention from nurses and other health care workers that extends beyond the existing and inadequate social network.


LITERATURE REVIEW

Several studies are available that describe the social and health risks endemic in the lives of street children throughout the world.

By combining short interviews with the recording of children’s height and weight on growth, Nzimakwe and Brookes (1994) were able to document both physical and social deprivation in fifty street children in Durban, South Africa. Ayaya and Esamai (2001) had similar findings: of the 56 abandoned children in their study, 52% were stunted and 64% were underweight. Other researchers have found evidence of parasite infection in 59% of 195 street children; 34% of this group also had cutaneous scarring (Scanlon, Tomkins, Lynch & Scanlon, 1998). Rew (2002) reports that this population has a high unmet need for treatment of sexually transmitted infections and mental health problems, including suicide.

Several researchers have documented the ubiquitous nature of substance abuse among street children. For example, Pinto and colleagues (1994) found over 80% of 195 street-based children from Belo Horizonte, Brazil used drugs regularly, with glue an easily available way to cope with the stresses of hunger, fear, and other realities of life on the street (Scanlon, Tomkins, Lynch, & Scanlon, 1998). A lower rate of solvent use (40%) was found among the 105 street children from Porto Alegre described by Forster, Tannhauser and Barros (1996). Noto and colleagues (1997) documented regional differences in the substance used—while solvents and marijuana were used at an equal rate (68% and 53%) among the 565 children in five areas of Brazil, cocaine and crack use was largely restricted to the southeast part of the country. The use of coca paste and flunitrazepan (Rohypnol) by street youth of Rio was documented as a large problem of the 1990’s, and there is little reason to believe the situation has changed today (Inciardi & Suarratt, 1998). Ribeiro & Trench Ciampone (2001) learned from their interviews with 14 children in a São Paulo shelter that inhaling glue was an essential condition of acceptance by peers on the street.

Robinson and colleagues (2001) discussed sexual behavior issues identified in focus groups by street boys from Kingston, Jamaica, which included an inability to obtain condoms, multiple sex partners and substance use. The authors also noted that the boys displayed negative attitudes toward condom use, intolerance toward homosexual behavior, and physical abuse directed at girls.  

A study by the Pan American Health Organization with a similar Caribbean population suggested that 42% of the school-aged population had initiated sexual intercourse by age ten (http://www.paho.org/English/ HPP/HPF/ADOL/SRH.pdf). In a study of 141 street youth from seven South African cities, Swart-Kruger and Richter (1997) found HIV knowledge levels similar to those of “hard-to-reach” adolescents in other parts of the world. In this group, the overwhelming need for food, money, and clothing made fear of HIV infection a minimal concern, despite the high prevalence of disease in South Africa. Malamud (1995) studied 143 children in Guatemala and found that all were sexually abused, 53% by a family member, and 71% had sex on regular basis, 25% with more than four partners daily; none of those surveyed used contraception. Anarfi (1997) noted two common practices among 1147 street children in Accra, Ghana that could have a significant negative impact on their health: initial sex with a prostitute and self-medication for STD symptoms. Among 54 homeless girls in Belo Horizonte, Brazil, pregnancy was almost universal, with over 25% of the group reporting at least one illegal abortion (Scanlon, Tomkins, Lynch, & Scanton, 1998). In their work in Austin, United States, Rew, Fouladi, and Yockey (2002) found that 35% of 414 homeless youth surveyed considered themselves to be bi- or homosexual; for this group, sexual orientation was the most common reason for leaving home.

Violence is present in many forms for children in this population. Inciardi and Surratt (1998) describe how street children in urban Brazil were frequently the target of local vigilante groups, drug gangs, and police “death squads”. The link between political violence and street children was explicit in Veale and Don’s (2003) report on the impact of the death or imprisonment of family members and the resultant loss of family, community, and social support experienced by 290 street children in post-genocide Rwanda. Lalor (1999) found similarities in the commonplace nature of violence among street children in both Latin America and Ethiopia. In his sample of 28 children, more than half reported being “regularly” physically attacked. In a Brazil study, 20% of the children had attempted suicide (Noto, et al., 1997).  Sexual abuse and victimization are common for girls: 44% had been raped and an additional 26% sexually attacked in other ways. Table 1, adapted from Lalor (1999) summarizes the nature and incidence of victimization among a sample of 69 Latin American girls. A description of children in Cape Town, South Africa who have been successful in dealing with the violence in their lives found the same traits noted in the literature on resiliency (Ramphele, 1997). These include intelligence, friendly disposition, future orientation, involvement in sports, and a positive relationship with any family member or adult (Ramphele, 1997).


Table 1- % Violence Experienced by Girls of the Street (n=69)  

 

 

 Theft

 Beating

Solicitation

 Rape

Prostitution

Sexual Attacks

Pregnancy

 81

  78

  75 

44

 44   

 26

 25

 

 

There is considerably less information available in the literature about interventions that address the problems faced by street children throughout the world. The use of art therapy for both for assessment and therapy of abandoned children in Kiev, Ukraine was noted by Arrington & Yorgin (2001), and Lowry (1995) showed how art can be used to capture the imagination of street children and guide them away from substance use. Densley & Joss (2000) described innovative ways in which occupational therapy treatments can be delivered to street children. In a health education program with young adolescents in Cruz Alta, Brazil that focused on hygiene and sexuality, Brum and Pereira (1996) described the use of progressive pedagogy techniques. The strategies of Passage House in its HIV prevention work with homeless girls in Recife, Brazil have been documented by Kanul (1991). Finally, Filgueiras (1992) detailed the specific strategies used to work with street children themselves to implement an HIV prevention/health promotion program.

This article contributes to the intervention literature by documenting the activities and population of Projeto Quixote, an innovative, university-community program working with impoverished youth in São Paulo, Brazil. We conclude by suggesting gaps in the research literature that academic and community nurses can fill both as part of their practice and research work and as part of the nursing profession’s responsibility to address facilitate social problems.


CASE DESCRIPTION OF PROJECTO QUIXOTE

The multi-disciplinary team of Projeto Quixote provide direct service, primary prevention, and consultant services about policy issues relevant to the lives of children with minimal or no family strucctures. Located in the southern area of the city of São Paulo, the program began in the mid 1990’s when faculty from the Department of Psychiatrity of the Universidade Federal de São Paulo met with street eductors from the Secretariat of Children, Family & Welfare of the state of São Paulo (now called the Secretariat of Welfare & Social Development) and discussed the urgent need for programs for children living temporarily or permanently on the streets of many neighborhoods of their city. The group decideded to develop a program that would offer a pragmatic alternative to everyday challenges such as drug abuse, violence, and the lack of family ties or role models faced by this special population of children. The group’s medical and social service backgrounds provided them with insight into the type of programming that could help bridge the transition between childhood and adolescence and that would offer an alternative social network to keep both boys and girls away from the streets. Three basic principles guided their work:

  1. Respect for human suffering and the right of people to make their choices
  2. Humanization of services
  3. Holistic approach to health.

In additional to developmental theories that reflect the physical, psychological, social, and emotional needs of children prematurely forced into adult situations, the group studied and discussed ways to apply the theories of Paolo Freire, the Brazilian educator (1921-1997). His text, Pedagogy of the Oppressed (1970), provided three important guidelines for their work:

  1. A dialogue or conversational process would supercede the use of a set curriculum of educational materials;
  2. Praxis, that is, that actions informed by values, would be the basis of work
  3. Education and therapeutic interactions would be guided by the lived experience of participants as much as by the professional knowledge of staff.

 

Examples of the current work of Projeto Quixote include:
Specific services to youth referred to the program by the courts, medical providers, or word-of-mouth, including teaching and homework assistance for those attending school, and, for those who do not, specific skills that will facilitate a return to school; legal assistance for those on probation or awaiting court hearings; and health care, including gynecology, psychiatric, substance abuse treatment, psychology evaluation, and dental services;

Skills training from 1) the Quixote Spray Art Project in which participants learn about design, preparation, application of paint materials, finishing, and marketing of products from local artists; 2) Hip-Hop Urra Project, where, in addition to coordinating dance and music presentations, young people develop a cultural context for their work. Pride in the culture of hip-hop provides an important option for young people with minimal avenues of expression for racial or ethnic pride.

Outreach prevention work based in a small low-income community of central São Paulo. The community has a very young population (one/third of the population is below age 18), and a high rate of economic poverty (fully half of families live below the official poverty level and another 25% below the misery level). Activities like crafts or bread making provide a space for exchange of ideas and informal teaching of parenting skills, child development, and family nutrition, as well as building relationships and providing role models for young.

Policy work, with over 1500 teachers and government workers attending the project’s educational and technical seminars documenting the medical and psychological issues of at-risk children and strategies for addressing them in São Paulo.

Current team members include psychiatrists, pediatricians, psychologists, counselors, and classroom and vocational arts teachers. Unfortunately, there has been a notable lack of interest in or participation from nurses. Staff is recruited through both formal and word-of-mouth contacts; the ability to relate well to and serve as a role model for the project’s young people is as important as formal educational qualifications.


Projeto Quixote Population
In the seven years of its existence, 1500 children and adolescents have passed through the doors of Moinho (“windmill”), the welcoming space of the Projeto Quixote’s program headquarters. Staff now work with approximately 200 children each month and provide in-depth support and counseling services to 250 families each year. A prevalence survey conducted with 290 children who attended the program at one point in mid-2002 found more than twice as many young men attending programs than young women (71 vs. 29%). While most are between the ages of 13 and 17 (70.5%), 23% are less than 12 years of age. Over half are not attending school, and of those attending, more than half are in the wrong grade for their age level. Over 70% acknowledged using drugs other than alcohol and tobacco. A unique feature of the program is its policy of no exclusion criteria. Staff will see children who walk in on their own, who come because their friends have told them about the project, who were referred by other organizations, or who heard about the project from a community event. While other agencies might not see children who are over 17 years or under 12 years of age, or using drugs, or with concurrent psychiatric illness, Quixote staff work to develop individualized solutions to the seemingly endless variety of problems presented by the children who find their way to the program.


A RESEARCH AGENDA

Research about street children provides advocates and policy makers with an important resource to change the conditions responsible for the etiology and perpetuation of this very human social problem. Four broad areas in which nurses might take a leadership role or work with collaborators from other disciplines include:

1) Background research about the numbers and demographic make-up of the population of street children in a particular community. Such information is an important starting place for the initiation of any intervention program. Documentation about the prevalence of risk behaviors such as the quantity and quality of violence in the lives of young people, sexual behaviors, and the use of substances can help to prioritize activities. Surveys of health indictors such as height, weight, body mass index, immunization status, dental caries, and nutritional intake can provide compelling evidence of need when presented to local health authorities.

2)Qualitative research that allows the voices of this vulnerable population to be heard. What are the strengths and resiliencies of study participants? What strategies do they employ to avoid arrest? How do they find food? How do they survive against the overwhelming obstacles? Which members of the group have made it off of the streets? How were they able to do this? Asking members of vulnerable populations such as street children what they understand about their own issues frequently provides important insights not available when an issue is studied from afar.

3)Action research done in collaboration with the target population (Kelly, 2003; Minkler & Wallerstein, 2003).Young people can provide input into all aspects of the research process, from selection of the research questions, to data collection as local ethnographers or other types of research assistants, to presentation of research findings. Researchers willing to invest in this process can gain rich insight into their population, provide important skills for participants, and have their research be a part of the change process.

4)Evaluation of service programs. Documentation of program impact is an essential component of continued funding. Developing process and outcome criteria, preparing findings for presentation, and carrying out a dissemination plan are all areas in which nursing professionals can work with community organizations to document the need for and successes of a program.


CONCLUSION

Whether a child is able to be quickly reunited into a home and family situation, lives on the streets for an extended period of time, or has his or her status as a child of the streets end with the coming of adult age, the ongoing existance of this vulnerable population throughout the world is a major social problem. Intervention work in the form of health education, social services, and training to provide economic options is illusive for the international population of children living in the streets. On the streets of São Paulo, Projecto Quixote provides both rehabilitative and preventive programs to address the needs of high-risk and high-need children (Inciardi & Surratt, 1998). Nurses with education in community health, public health, and research methods can make a significant contribution to the profession by contributing to or initiating programs, documenting processes, and evaluating the outcomes of their work with this population.


REFERENCES

1. Anarfi, J. (1997). Vulnerability to sexually transmitted disease: Street children in Accra. Health Transition Review, 7 suppl, 281-306.

2. Aneci, R., Borba, E., Ebrahim, G. (1992). The street children of Recife: A study of their background. Journal of Tropical Pediatrics, 38, 34-40.

3. Arrington, D. & Yorgin, P. (2001). Art therapy as a cross-cultural means to assess psychosocial health in homeless and orphaned children in Kiev. Art Therapy, 18, 80-8.

4. Ayaya, S. Esamai, F. (2000). Health problems of street children in Eldoret, Kenya. East African Medical Journal, 78, 624-9.

5. Barker, G. (1992). More than a minor problem. Instituto de las Americas Hemisfile, 3, January, 6.

6. Barrett, K. (1999). Editor’s choice: The plight of a people dispossessed: Caring for street children in the mountains of Bulgaria. Journal of Pediatric Nursing, 14, 213-21.

7. Brum, Z. & Pereira, M (1996). [ Health education focusing on hygiene, sexuality, and drug addiction for street children, 11-14 ]. Revista Brasileira de Enfermagem, 49, 333-42.

8. Densley, M. Joss, D. (2000). Street children: Causes, consequences, and innovative treatment approaches. Work, 15, 217-25.

9. Ehiemere, I. (2000). Street children phenomenon: Health and social perspectives. West African Journal of Nursing, 11, 27-31.

10. Figueiras, A. (1992). Taking health promotion on to the streets. AIDS Action, 17.

11. Forster, L., Tannerhauser, M. Barros, H. (1996). Drug use among street children in southern Brazil. Drug Alcohol Dependence, 43, 57-62.

12. Freire, P. (1970). Pedagogy of the oppressed. New York: Seabury.

13. Inciardi, J. Surratt, H. (1998). Children in the streets of Brazil: Drug use, crime, violence, and HIV risks. Substance Use Misuse, 33, 1461-80.

14. Kanul, F. Vasconcelos, A. (1991). Passage House as a model for AIDS education of street children. AIDS Education Prevention, 3, 73.

15. Kelly, P. (2003). Getting started in participatory action research. Public Health Nursing, (in press).

16. Lalor, K. (1999). Street children: A comparative perspective. Child Abuse Neglect, 23, 759-70.

17. Lowry, C. (1995). Reaching street youth on substance abuse. World Health Forum, 16, 131-4.

18. Malamud, S. (1995). At risk and abandoned: Street children, AIDS and human rights. AIDSlink: Eastern, Central Southern Africa, 31, 6-7.

19. Minkler, M. Wallerstein, N. (Eds.) (2003). Community-based participatory research for health. San Francisco: Jossey-Bass.

20. Noto, A. , Nappo, S., Galduroz, J., Mattei, R., Carlini, E. (1997). Use of drugs among street children in Brazil. Journal of Psychoactive Drugs, 29, 185-92.

21. Nzimakwe, D. Brookes, H. (1994). An investigation to determine the health status of institutionalized street children in a place of safety in Durban. Curationis, 17, 27-31.

22. Pinto, J., Ruff, A., Paiva, J., Antunes, C., Adams, I., et al. (1994). HIV risk behaviour and medical status of underprivileged youths in Belo Horizonte, Brazil. Brazilian Journal of Adolescent Health, 1994, 15, 179-85.

23. Ramphele, M. (1997). Adolescents and violence: “Adults are cruel: They just beat, beat, beat!” Social Science Medicine, 45, 1189-97.

24. Rew, L. (2002). Characteristics and health care needs of homeless adolescents. Nursing Clinics of North America, 37, 423-31.

25. Rew, L., Fouladi, R., Yockey, R. (2002). Sexual health practices of homeless youth. Journal of Nursing Scholarship, 34, 139-45.

26. Ribeiro, M. Trench Ciampone, M. (2001). Homeless children: The lives of a group of Brazilian street children. Journal of Advanced Nursing, 35, 42-49.

27. Robinson, T., Thompson, T., Bain, B. (2001). Sexual risk-taking behavior and HIV knowledge of Kingston’s street boys. Journal of AIDS Prevention Education of Adolescent Children, 4, 127-47.

28. Scalon, T., Tomkins, A, Lynch, M. & Scanlon, F. (1998). Street children in Latin America. British Medical Journal, 316, 1596-1600.

29. Swart-Kruger, J. Richter, L. (1997). AIDS-related knowledge, attitudes and behaviour among South African street youth: Reflections on power, sexuality and the autonomous self. Social Science & Medicine, 45, 957-66.

30. Veale, A. & Don, G. (2003). Street children and political violence: A socio-demographic analysis of street children in Rwanda. Child Abuse & Neglect, 27, 253-69.

 


Received:   07/01/2003
Accepted: 07/25/2003

 





 

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