Citation:
. KELLY,
P.J.; GRAJCER, B.; RIGATO, F. D. Children Living on the
Street.
Online
Brazilian Journal of Nursing (OBJN_ISSN
1676-4285), v.2, n.2, 2003 [Online]. Available at: www.uff.br/nepae/objn202kellyetal.htm
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.
Key words: street children, vulnerable populations, literature review
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.
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.
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:
Respect
for human suffering and the right of people to make their choices
Humanization of services
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:
A
dialogue or conversational process would supercede the use of a set
curriculum of educational materials;
Praxis,
that is, that actions informed by values, would be the basis of work
Education
and therapeutic interactions would be guided by the lived experience of
participants as much as by the professional knowledge of staff.
·
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.
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.
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.
Anarfi,
J. (1997). Vulnerability to sexually transmitted disease: Street children in
Accra. Health Transition Review, 7 suppl, 281-306.
Aneci,
R., Borba, E., & Ebrahim, G. (1992). The
street children of Recife: A study of their background. Journal of Tropical
Pediatrics, 38, 34-40.
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.
Ayaya,
S. & Esamai, F. (2000). Health
problems of street children in Eldoret, Kenya. East African Medical Journal,
78, 624-9.
Barker,
G. (1992). More than a minor problem. Instituto de las Americas
Hemisfile, 3, January, 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.
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.
Densley,
M. & Joss, D. (2000). Street children: Causes, consequences, and innovative
treatment approaches. Work, 15, 217-25.
Ehiemere,
I. (2000). Street children phenomenon: Health and social perspectives. West
African Journal of Nursing, 11, 27-31.
Figueiras,
A. (1992). Taking health promotion on to the streets. AIDS Action, 17, .
Forster,
L., Tannerhauser, M. & Barros, H. (1996). Drug use among street children in
southern Brazil. Drug & Alcohol Dependence, 43, 57-62.
Freire,
P. (1970). Pedagogy of the
oppressed. New York: Seabury.
Inciardi,
J. & Surratt, H. (1998). Children
in the streets of Brazil: Drug use, crime, violence, and HIV risks. Substance
Use & Misuse, 33, 1461-80.
Kanul,
F. & Vasconcelos, A. (1991). Passage
House as a model for AIDS education of street children. AIDS Education &
Prevention, 3, 73.
Kelly,
P. (2003). Getting started in participatory action research. Public Health
Nursing, (in press).
Lalor,
K. (1999). Street children: A comparative perspective. Child Abuse &
Neglect, 23, 759-70.
Lowry,
C. (1995). Reaching street youth on substance abuse. World Health Forum, 16,
131-4.
Malamud,
S. (1995). At risk and abandoned: Street children, AIDS and human rights. AIDSlink:
Eastern, Central & Southern Africa, 31, 6-7.
Minkler,
M. & Wallerstein, N. (Eds.) (2003). Community-based participatory
research for health. San Francisco: Jossey-Bass.
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.
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.
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.
Ramphele,
M. (1997). Adolescents and violence: “Adults are cruel: They just beat, beat,
beat!” Social Science & Medicine, 45, 1189-97.
Rew,
L. (2002). Characteristics and health care needs of homeless adolescents. Nursing
Clinics of North America, 37, 423-31.
Rew,
L., Fouladi, R., & Yockey, R. (2002). Sexual health practices of homeless
youth. Journal of Nursing Scholarship, 34, 139-45.
Ribeiro,
M.& Trench Ciampone, M. (2001). Homeless
children: The lives of a group of Brazilian street children. Journal of
Advanced Nursing, 35, 42-49.
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.
Scalon,
T., Tomkins, A,, Lynch, M. & Scanlon, F. (1998).
Street children in Latin America. British Medical Journal, 316,
1596-1600.
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.
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:
July 1st, 2003
Accepted: July 25th, 2003