Programme on Substance Abuse
July 1993 (WHO/PSA/93.7)

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.

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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

    Project Aims
    Expected Outcomes
    The Methodology - Process and Procedures for Site Implementation

5. Evaluation of the Street Children Project

    Project Implementation Report
    Usefulness of the Modified Social Stress Model
    Evaluation of the Street Children Project by its Expected Process Outcomes

6. Conclusions

7. Recommendations


A. Participating Organizations
B. Principal Investigators
C. References

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.


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.

(TO PART 2 OF 9)

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