A One-Way Street?
Report on Phase I of the Street Children Project
Part 1 of 9
This report is reprinted in nine parts with permission of the World Health Organization, Programme on Substance Abuse, 1993. The document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated in part or in whole, but not for sale nor for use in conjunction with commercial purposes.
The views expressed in documents by named authors are solely the
responsibility of those authors.
WORLD HEALTH ORGANIZATION
PROGRAMME ON SUBSTANCE ABUSE
CH-1211 Geneva 27
Switzerland
Tel 791. 21.11
Among the estimated 100 million street children worldwide, the
use of alcohol and other drugs is a major concern. In a
population vulnerable to a range of health and social problems,
the problems associated with substance use add to the overall
burdens of their lives. Street children constitute a
marginalized group in most societies, where accessibility to
health care and other services is severely restricted. For those
street children who use drugs, discrimination and marginalization
remain major obstacles to effective interventions.
The WHO Programme on Substance Abuse (PSA) initiated a pilot
project in 1991, with funding support from the international Drug
Control Programme (UNDCP), to investigate and respond to the
problem of substance use among street children. The project has
aimed to address this problem utilizing rapid assessment
methodologies and community development approaches. Placing the
issue of substance use in the wider context of risk behaviours, a
desired outcome of the project is an increase in the utilization
of, and access to, health care services by street children.
The report describes the implementation of the pilot project,
focusing on process evaluation and project operationalization.
Over 550 street children from 10 cities (Rio de Janeiro,
Alexandria, Cairo, Montreal, Toronto, Bombay, Tegucigalpa, Mexico
City, Manila and Lusaka) participated in focus groups or were
interviewed individually. The report includes information
obtained from street children concerning the extent and nature of
substance use and other risk behaviours within different street
children populations; the structures and activities of
organizations working with these populations; a range of
interventions which are currently being used; and a series of
recommendations for further action.
Evaluation of the project concludes that the methodology and
instruments used are sound, useful and well accepted in all
centres which participated in the pilot. It is recommended that
the project methodology and instruments be further refined and
that training guidelines and resources for street educators be
developed.
1. Executive Summary
2. Introduction
3. Substance Use, Health and Street Children: A Background Drug
4. The Street Children Project
5. Evaluation of the Street Children Project
6. Conclusions
7. Recommendations
Annexes:
A. Participating Organizations
Note: In this report "Street Children" will be used to indicate
males and females aged to 25, who spend the greater part of their
days in the streets of urban environments. However, the majority
of those involved in the Street Children Project of PSA are below
the age of 18.
Use of Young People
A Model of Risk for Drug Use
Street Children
Health of Street Children
Drug Use and Street Children
Use of and Access to Services
Reliability of Information
Gender IssuesProject Aims
Objectives
Expected Outcomes
The Methodology - Process and
Procedures for Site Implementation
Project Implementation Report
Usefulness of the Modified Social Stress Model
Evaluation of the Street Children Project by its
Expected Process Outcomes
B. Principal Investigators
C. References
In 1991, the WHO Programme on Substance Abuse (PSA) made a
commitment to develop a project focusing on the issue of
substance use with regard to street children. Funding was
received from the United Nations International Drug Control
Programme (UNDCP) for development and implementation of the
project. The nature of continuous exposure to the streets and
the associated lifestyles make street children vulnerable to a
range of health and other problems which are not typically
experienced by other young people. Within different societies,
compared with other groups of young people of similar age, street
children in general are more likely to use drugs. Although
functional in most circumstances, their drug use tends to add to
their health and other difficulties. Traditionally, young people
under-utilize existing health services. For marginalized youth,
such as street children, mainstream health services are often
viewed with suspicion and are avoided. While at the same time,
such health services rarely understand the circumstances and
specific needs of these young people. In addition, they often
are not able to provide services which are accessible and
acceptable to this population.
The project has aimed to address these issues by developing a
practical framework within which specific organizations can
assess the nature and extent of the problem of street children
and drugs in their own communities and to develop and implement
appropriate responses. The basis of such an approach is one of
community involvement, organization, development and advocacy.
Critical to this process is the actual involvement of street
children at all levels of project planning, implementation and
evaluation. One desired outcome is an increase in the
utilization by street children of, and their access to, existing
services. The project places the issue of drug use within the
wider context of risk behaviours.
Initial research by PSA led to the development of a theoretical
model and related methodology and instrumentation. Seven
developing countries were selected in which street children were
recognized to have problems: Brazil, Egypt, Honduras, India,
Mexico, the Philippines and Zambia. Representatives from
different centres in these countries met at the World Health
Organization headquarters in Geneva in February 1992 to report on
the situation for street children in their country or city, to
discuss the project methodology and instruments, to consider the
role of PSA in addressing this problem, and to set objectives and
plans for implementation of the project.
Following the return of meeting participants to their
respective countries, organizations which worked with street
children were selected to pilot the methodology. These
organizations were briefed, personnel selected to implement
rapid assessment procedures, including focus groups, and community
advisory committees in most centres were established. Over 550
street children participated in focus groups, or were interviewed
individually. From the information obtained, some centres
developed strategic plans. These qualitative research
methodologies were utilized for data collection in order to
provide a descriptive characterization of the situation in each
centre.
This pilot phase, primarily as a feasibility study, has
demonstrated that the methodology is sound. This phase did not
emphasize the collection of quantitative data. The participating
organizations expressed enthusiasm for the project, found the
model, methodology and instrumentation extremely useful and were
eager to move to the next phase of the project which will be a
more rigorous and focused implementation of a refined
methodology. Site visits were conducted by a PSA Consultant,
and these were found to be useful, even essential to the
operation of the project at this time. By the end of the first
phase of the project, most centres had implemented specific
intervention strategies based upon local situation assessments.
This report, prepared by Dr. Andrew Ball from the Programme on
Substance Abuse and Mr. John Howard, a consultant to PSA,
describes the exploratory work which has been undertaken during
the first phase of the project. The descriptive nature of the
report provides valuable insights into the life of street
children and the activities of organizations working with them.
Particular attention has been focused on issues of process
and project operationalization. Where examples have been given,
care should be taken not to generalize or universalize. Care
should also be taken when interpreting figures which are
presented in the report as rigorous quantitative data collection
methodologies have not been implemented.
From a review of the participating organizations' final reports
on Phase I and the reports of the PSA Consultant who conducted
site visits, certain recommendations follow:
For PSA consideration:
1. It is recommended that a second meeting be held, in workshop
format for all participating centres, invited experts and
selected international organizations. This meeting might ensure
that the senior front-line implementors be involved, and focus on
refining the methodology, develop training materials and
guidelines and set objectives for further phases of the project.
2. It is recommended that project implementation and evaluation
be supported at field level through site visits by a PSA
Consultant.
3. It is recommended that a mechanism be established whereby
street children will be able to participate in the overall PSA
evaluation of further phases of the project.
4. It is recommended that closer relationships develop with other
WHO programmes such as the Global Programme on AIDS, Adolescent
Health, Maternal and Child Health and Family Planning, Health
Education, and the Division of Mental Health so that interventions are maximized and holistic, and that duplication of
interventions is minimized.
5. It is recommended that a closer relationship develop with
other relevant United Nations instrumentalities, in particular
UNICEF.
6. It is recommended that efforts be made to identify
international organizations which act as clearinghouses for
information on street children and drug use, and on interventions
and strategies found to be useful. Where possible, coordination
of such activities should be encouraged.
7. It is recommended that PSA widely disseminate this report of
the first phase of the Street Children Project using such
networks as UN and nongovernmental organizations, and to use
the findings of this project to advocate for a more active
international response to the problem.
For participating organization considerations - administrative:
8. It is recommended that participating organizations pay
particular attention to the sustainability of their programmes.
As part of developing the infrastructure for their programmes,
local fundraising should not be ignored, and self-sufficiency
should be aimed for. Obstacles to achieving such an aim need to
be recognized. The project should be developed to include
practical strategies which may be implemented by local
organizations in order to ensure the sustainability of their
programmes.
9. It is recommended that participating organizations ensure
that Community Advisory Committees are representative of the
community so that empowerment and community development become
realities.
10. It is recommended that each participating organization
acknowledge and respect the United Nations Convention on the
Rights of the Child.
11. It is recommended that the safety of street children and
workers, and ethical standards of practice be ensured and
reported on in the implementation of the Street Children Project
at a local level. Where implementation of the project, or any
part thereof, increases such risks, implementation should be
reviewed.
12. Recognizing particular cultural contexts and limitations, it
is recommended that any moral biases evident in the way focus
groups are conducted or in strategic plans be examined and, where
possible removed.
13. It is recommended that organizations that serve the needs
and interests of street children establish clearly stated
policies as a basis for actions concerning drug use, HIV
infection and other important health problems among street
children.
For review of project methodology and instruments:
14. It is recommended that there be a reduction in the number of
questions in the menus, thus increasing flexibility for
preventive interventions during focus groups.
15. It is recommended that validity checks be incorporated within
the data collection instruments.
16. It is recommended that a reduction in emphasis on the
collection of statistics occur.
17. It is recommended that the appropriateness of other rapid
assessment methodologies for the project be investigated.
18. It is recommended that a simple data collection format be
developed allowing for local data organization, analysis and
interpretation.
19. It is recommended that simple practical guidelines for
local evaluation be developed and promoted.
Focal issues - street children:
20. It is recommended that participating organizations maximize
street children participation.
21. It is recommended that street children be involved, as
appropriate, in the development of Strategic Plans, should be
represented on Community Advisory Committees and play an active
role in the evaluation process.
22. It is recommended that a holistic approach be maintained,
but with a special emphasis on and strategies for targeting risk
behaviours including drug use and unprotected sex.
23. It is recommended that special attention be given to
prevention and interventions related to the use of organic
inhalants. This need is considered to be urgent due to the
almost universal use of such substances by street children in
developing countries.
24. It is recommended that "resilient" street children (those
in difficult circumstances and yet who do not use drugs) become a
focus of investigation.
25. It is recommended that interventions developed should draw
on the strengths and resources of street children themselves,
utilizing such approaches as self-organization by street children
and self-help groups.
26. It is recommended that the potential benefits of issuing
identification cards to street children involved with
participating and other organizations be considered, as a
possible means of enhancing access to services and as an aid
if children come into contact with the authorities. Any
potential risks associated with such a strategy should be
determined.
27. It is recommended that more attention be given to exploring
the reasons for separation from family of origin and the impact
of various issues associated with the separation. For example,
age, developmental stage, specific circumstances of the
separation.
28. It is recommended that attention be given to activities
which strengthen families from which street children come to
aid return to the family of those children willing to do so.
In addition, attention needs to be given to the recruitment
of host families.
For recruitment and training of street educators:
29. It is recommended that decisions be made as to criteria
for the selection of street educators.
30. It is recommended that strategies, resources and guidelines
for the training of street educators be identified, developed and
tested.
31. It is recommended that educational/preventive resources
which are developed to assist street children be developed
locally if possible, with maximum involvement at all stages
of production by the street children themselves.
32. It is recommended that the second phase of the project
focus on the training needs of street educators and others
working with street children.
33. It is recommended that participating organizations
explore opportunities for improving the safety of street
educators and protecting them from harassment.
In 1991, the Programme on Substance Abuse (PSA) made a
commitment to develop a project to focus on the issue of
substance use with regard to so called "street children".
Funding was received from the United Nations International
Drug Control Programme for the development and implementation of
the project. Street children constitute a marginalized
population in most urban centres of the world. Street children
who use drugs are even more marginalized and are neglected in
relation to the provision of services. The initiation of the
project was seen as an opportunity to raise national and
international awareness of the needs of this group, the current
tragedy of many of their lives, and to advocate for urgent and
planned strategies to be implemented both for preventing and
reducing harm associated with drug use by this population.
Particularly in developing countries, where street children are
often much younger, they can provide a powerful image of how
drugs can affect a whole community. With some street children,
most of life revolves around the manufacture, distribution and
use of drugs, with their basic means of survival, access to
services and protection linked to compliance with and the
support of those members of their communities who are involved in
the drug industry.
Concern for this population has arisen also due to the global
spread of HIV/AIDS. Street children are vulnerable through
sexual exploitation and now drug use. Street children who are
injecting drug users and/or who practice unsafe sex are also seen
as one potential bridge for the spread of infection to the
broader community. This could occur via the adults who share
injection equipment with them or use them for sex.
After some initial research and the development of a model to
inform situation assessment and interventions, PSA selected
seven countries, representing diverse cultural settings, to pilot
the project. These countries were: Brazil, Egypt, Honduras,
India, Mexico, the Philippines and Zambia. The selection of the
countries reflected the belief that the prevalence and needs of
street children are greater in developing countries. The
selection does not intend to deny or ignore the plight of street
children in more developed countries.
A meeting was held in Geneva (3 to 7 February, 1992) of
representatives of key organizations involved in working with
street children from the seven countries selected, to obtain a
briefing on each participating country's situation with regard to
their street children and their drug use, to discuss the project,
to consider the role of PSA in addressing the problem, to review
the instruments and methodology developed in late 1991, to set
objectives and to prepare a plan for implementation of the
project. The project was enthusiastically received, and the
participating representatives were appreciative that the voices
of street children and those working with them were being taken
seriously and receiving global attention. They felt that the PSA
initiative reinforced, by attention to street children who use
drugs, the increasing concern of other United Nations'
organizations, such as International Labour Organization (ILO),
UNICEF and UNDCP.
The use of drugs, particularly in this population, has health
implications, and therefore WHO is ideally located to address
such issues.
After this meeting, each participating country began to pilot
the project in key cities (Rio de Janeiro, Cairo and Alexandria,
Tegucigalpa, Bombay, Mexico City, Manila, and Lusaka) under the
auspice of a key nongovernmental organization (NGO) or a
governmental institution. Toronto and Montreal joined the
project at a later stage. In certain circumstances some NGOs
received direct governmental support. Site visits were conducted
by Dr. Andrew Ball of PSA between September and November, 1992
and each NGO provided written reports on their progress.
On completion of the first phase of the project each
participating centre conducted a workshop to disseminate
information on the project methodology and findings.
Participation in the workshop varied across centres and included
health professionals, street educators, welfare workers,
educators, government officers, law enforcement representatives
and representatives of NGOs.
In order to locate the project and its methodology, a brief
review of what is known of the drug use of young people and
a conceptual model follows, together with the implications of
drug use for street children. The project methodology will then
be described and reviewed in relation to the usefulness of the
conceptual model and expected outcomes.