PROTOCOL: Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street‐connected children and young people

Abstract

The number of street-connected children and young people worldwide has been estimated at around 100 million (UNICEF 2002), although this figure is widely contested. It is recognised that exact numbers are unknown and estimates vary, due in part to political motivations (CSC 2011). Numbers differ depending on whether estimated by governments or non-government organisations (NGOs), and the definition and status of the problem has traditionally differed for Europe and other high income countries, although some of the structural antecedents such as inequalities or social exclusion may be similar. For example, a minimum of 66,000 first-time runaways per year is recorded in England (CSC 2009), and Canada's street-connected children and young people may be runaways who have escaped sexual or physical abuse. Data for the US estimate 1 to 2 million ‘street involved youth’. The difficulty in estimating numbers is in part due to wide variations in definitions of which young people are included and the lack of formal identity papers, for most street-connected children and young people. The definition of ‘street-connected children and young people’ can overlap with other categories such as runaways and homeless youth, children who have been trafficked, child labourers, migrant children, children who live in slums, and children living in institutions (Ennew 2003; UNICEF 2005). Many commentators argue that the issues prevalent in the lives of street-connected children, including the risks, do not differ for other children living in urban or rural poverty, and that approaches to the issue of street-connected children and young people should not be disconnected from approaches to ameliorate poverty and social exclusion more generally (CSC 2011; Panter-Brick 2002). This review however focuses on street-connected children. Definitions, too, are much debated and contested, particularly in light of the research that highlights young people's agency and resilience (Beazley 2003; Van Blerk 2006). Qualitative studies conceptualise agency as an element of young people's resilience-building capacity, enabling street-connected children and youth, for example, to negotiate for their basic needs, draw on social support networks, and explore pathways to achieve their personal goals in a resourceful manner (Theron 2010). A summary from the overview by the Consortium for Street Children (CSC) states: “street children are recognized to be young people who experience a combination of multiple deprivations and ‘street-connectedness'” (CSC 2011). Children and young people may live and work on the street or in public spaces, work on the street and return to family homes or hostels at night, or a combination of these at different time periods. For the most part, they experience complex social and economic circumstances that “defy easy definition” (CSC 2011). Current thinking sees this process as non-linear, with many street-connected children and young people transitioning off the streets (Panter-Brick 2002). This definition opens the door to studies of young people living in slums/squatter settlements or in hostels, who are also working on the street. In our systematic review, the term ‘street-connected children and young people’ is used to refer to children who work and/or sleep on the streets and may or may not necessarily be adequately supervised or directed by responsible adults, and includes (but not exclusively), the coexisting categories referred to by the United Nations International Children's Emergency Fund (UNICEF) as those ‘on the street’ and those ‘of the street’ - ‘children for whom the street is a reference point and has a central role in their lives’ (CSC 2011; Redes Rio Crianca 2007; UNICEF 2001a). In the historic UNICEF definition, ‘children of the street’ are homeless children who live and sleep on the streets in predominantly urban areas, living with other street-connected children and young people or homeless adults. ‘Children on the street’ earn their living or beg for money on the street and may return home at night, and maintain contact with their families. Such definitions may include children who are stateless or migrating, with or without their families. Important risks faced by street-connected children and young people are physical, psychological and sexual exploitation, violence, economic exploitation, social exclusion, no skills-based employment, substance misuse, widespread addiction, and HIV (Ennew 2000; West 2003). Many street-connected children and young people experience health difficulties, coercion and control by adult gangs, criminality and lack of education (West 2003). However, street-connected children and young people are not a homogenous group. Current research demonstrates that girls and young women may experience risks differently to boys and young men (Beazley 2003; Van Blerk 2006). Other groups, such as disabled youth or those from minority ethnic groups, may also have different experiences. Children live and work on the streets in different ways and for different reasons (UNICEF 2005). Most street-connected children and young people are not orphaned but are in contact with their families and may augment the household income (UNICEF 2005). Current research also emphasises the resilience of street-connected children and young people and the fact of children and young people's agency and citizenship, making their own decisions and with a need for participation, not solely protection (CSC 2011; Panter-Brick 2002). Interventions aiming to improve the situation of street-connected children and young people include educational projects (Ouma 2004), vocational training (Ali 2004), harm-reduction (Poland 2002), HIV prevention (Rotheram-Borus 2003), and projects focused on substance use, social stability, and physical and mental health (Slesnick 2007). They often take the form of single projects, drop-in centres or peer education interventions, and many of these projects will be underpinned by the ‘children's rights’ discourse, more recently taking a holistic approach to the needs of the young people (CSC 2011; Ennew 2000). Indeed, it has been argued that some interventions may not succeed if they ignore children's voices and do not include their participation in planning and management (Panter-Brick 2002). Educational projects offer street-connected children opportunities to break out of the cycle of poverty. Occasionally, these projects help children/youth to sit formal examinations and obtain recognised certificates (Ouma 2004), while vocational training aims to develop skills to lead children/youth into the world of non-exploitative work. Often these programmes aim, through health and nutrition programmes, to increase the ‘educatability’ of children/youth before or while they are attending schools. They can also take the form of non-formal education, consisting of any form of systematic learning activity outside the framework of the formal system. Such provision may be run alongside formal schooling, or separately. Several considerations are relevant with reference to the intervention population. So far, we have particularly identified gender, ethnicity, religion, disability, citizenship, legal status, and age of the street-connected children and young people as relevant individual factors that may impact on outcomes of interventions. There are also relevant contextual factors, which include the experience of sexual abuse, violence, addiction, low literacy, migration (including rural-to-urban), poverty, and mechanisms of exclusion (such as negative community responses to the children's migratory/refugee status, and labelling them as ‘vagrants’, ‘illegal vendors’, or ‘truants’). It is also important to consider the nature of strategies for engaging young people at street level that, according to a wealth of qualitative literature drawing on ethnographic data and practitioner perspectives, form the basis of successful intervention programmes (CSC 2011; Ennew 2000; Karabanow 2004; Panter-Brick 2002). “To determine the ‘type’ of intervention needed, engagement enables a relationship and trust to be built. Participatory models of engagement ensure that sufficient time and space is given to children to demonstrate to outsiders why they came to the street, and what their background is. Participatory engagement allows children themselves to tell their histories rather than have to directly answer questions about their past” (Walker 2011 [pers comm]). We have developed two preliminary logic models to capture the broad range of different approaches found in interventions for street-connected children and young people (Figure 1 and Figure 2). According to the Kellogg Foundation's Logic Model Development Guide, a logic model is “a systematic and visual way to present and share your understanding of the relationships among the resources you have to operate your progam [sic], the activities you plan, and the changes or results you hope to achieve” (Kellogg Foundation 2004). A logic model illustrates the connection between the work planned in an intervention and its intended results. Anderson 2010 described how logic models could be used at different stages of a systematic review, from conceptualising the review focus, to clarifying the interpretation of results. They argue that logic models offer a particularly useful tool in the analysis of complex interventions that operate at individual, group and social system levels in the fields of education, health, and social welfare. Drawing on this approach, we aim to use logic models in a dynamic way, developing and adapting our chosen models in response to relevant stages of our review (e.g. identifying effect mediators or moderators; subgroup analysis) and different audiences (e.g. policymakers and practitioners). This will aid us in communicating the results from what we anticipate, on the basis of previous studies (Altena 2010; Slesnick 2007), to be very heterogeneous data, in a format that is both methodologically and theoretically informative and increases the accessibility of our findings. Inputs in the two logic models in Figure 1 and Figure 2 describe the resources which are needed to implement an intervention for street-connected children and young people. The term ‘activities’ refers to what any intervention might do with these inputs. They are the processes, tools, events, technology, and actions that are an intentional part of the intervention implementation. Outputs are the direct products of the intervention activities and may include types, levels, and targets of services to be delivered by the intervention. Outcomes are specific behavioural, knowledge, skills, status and functional changes in the intervention participants. Sources differ in their proposed timeframes for distinguishing short, medium, and long term outcomes. In the two logic models we define short term outcomes as outcomes which occur within the lifetime of the intervention, and medium term outcomes as outcomes which occur within one to three years of the intervention. Long term outcomes can also be defined as ‘impact’, which is the fundamental intended or unintended change occurring in organisations, communities, or systems as a result of intervention activities within three to seven years (Kellogg Foundation 2004). These may however be difficult to identify or attribute to intervention inputs. The logic models (Figure 1 and Figure 2) can be read from left to right, and in this way describe intervention impact over time, from planning through to results. According to Kellogg Foundation 2004, it is useful to read logic models following the chain of reasoning (”if…then…”), connecting the different parts of any intervention. The two logic models we present are drawn from a range of qualitative, quantitative and narrative/overview sources (Gleghorn 1997; Kipke 1997; Kristof 2009; Ouma 2004; Slesnick 2007). An (limited) example of reading the logic model in Figure 1 would be: In order to engage street-connected children and young people in education, an intervention would need teachers and teaching materials, but also food, toilets and possibly sleeping facilities (inputs). If these are available, then the intervention could provide the children with opportunities to play and earn money. The intervention would also need to overcome the need for school uniforms by either providing them free of charge or not making uniforms a requirement (activities). The immediate output of this intervention may be that lessons are taking place (output). The intermediate outcome would be that children/young people attend these lessons. A short term outcome (i.e. within several months to one year) might be that children attend the lessons regularly, are not malnourished and gain self-esteem. Within one to three years these children can read and calculate, and are able to secure employment (medium term outcomes). In an even longer term perspective, this may lead to reintegration and greater inclusion in families and/or society and possibly reduce future poverty (impact). The lower box highlights contextual factors that affect the impact of an intervention or programme on individual children/young people, via the moderating effects of resilience factors conceptualised as internal and external assets, processes, and agency (Theron 2010). These contextual factors include age, gender, religion, legal status, addiction status, and other factors. They constitute factors present at the start of an intervention that may impact on outcomes or take-up of interventions. The logic model depicted in Figure 2 is more varied in its focus and includes aspects of health care, HIV prevention, pregnancy prevention, but also access to employment. As in Figure 1, the model needs to incorporate street-connected children and young people's interests, but also their strength and resilience in order to become involved in the intervention. Inputs include the availability of services (outreach workers, mental health services) but also ways of addressing basic needs such as housing and nutrition (inputs). If these inputs are achieved, activities need to include ensuring that the new environment is safe, includes learning opportunities, but also access to health care and condoms (for example). Outputs that need to be achieved are that street-connected children and young people know of and attend the intervention project, take-up health care and use more condoms. Within the life of the intervention, these components should lead to reduced risky drug use, health improvements, and increases in employment opportunities (short term outcomes). Within one to three years the intervention should then result in a reduced number of infections with HIV and other sexually transmitted infections (STIs), but also in a reduced number of pregnancies and generally better health. The intervention's longer terms impact (three to seven years) may be reintegration into families, communities and society, and reduced poverty. It may however be difficult to measure or demonstrate these longer term impacts. A final point to be made is that the circumstances of street-connected children and young people as noted above, may be non-linear, and young people may continue to live/work on the streets whilst engaging with interventions, and may take many years to reintegrate fully or become re-included within mainstream society. The rationale for this review is to assess the effectiveness of interventions for improving outcomes for street-connected children and young people and reducing the risks of the most adverse outcomes, to promote access to and integration into education, training, and employment opportunities, and more healthy and settled lifestyles. Such lifestyles include access to universal human rights such as survival, development, participation, and inclusion, although these may be difficult to measure. By addressing the above-mentioned outcomes, we explicitly aim to synthesise the evidence on reintegration approaches, including harm-reduction programmes. We propose to focus on inclusion, reintegration and harm-reduction interventions targeted at children and young people while they are living on or closely connected to the streets. For the purposes of this review, we define reintegration as the children and young people entering a residential and/or educational environment that has the potential to provide them with elements of physical safety, medical care, nutrition, counselling, education, inclusion in social and economic opportunities, and room for recreation and personal and spiritual growth that may impact positively on longer term life chances. Reintegration does not mean returning the children to the situations from which they may have escaped. Family reintegration is potentially a highly valuable outcome for many street-connected children and young people. However, the effectiveness as well as ethical implementation of interventions aiming at family reintegration, are premised on access to appropriate resources for assessment, support and follow-up, in recognition of the potentially significant risks associated with processes of family reintegration (Thoburn 2009). ‘Harm-reduction’ is an umbrella term to describe the interventions aimed at reducing harms associated with lifestyles of street-connected children and young people, including for example, those associated with early or risky sexual activity and substance use (UNICEF 2001b). Expressed in general terms, these would be interventions aimed at street-connected children and young people, and aiming to protect and promote both their welfare and their well-being while they are on the street so that they are able to benefit from more focused reintegration approaches when it is appropriate and possible for them to do so. All the long term recommendations we found at the UNICEF evaluation database are structural. However, the short term recommendations by UNICEF are based on principles of child protection that can be described as matching the harm-reduction approach. This is open to interpretation, but seems in line with the opinion of people working with street-connected children and young people consulted by members of our team: protection may be a necessary stage on the path to reintegration, alongside development and participation. We will use the World Health Organization (WHO) definition of ‘inclusion’. We believe that the results of a systematic review such as the one proposed here might be relevant to a large number of street-connected children and young people worldwide. The review will examine interventions that enable children to live safe and healthy lives that promote their rights, and support their pathways to adulthood. It will also highlight gaps in the current evidence base. We identified few rigorous reviews on the effectiveness of interventions to support street connected children and young people through a scoping search. Descriptive reviews of interventions which include literature on lower-middle-income and low-income countries Peters 2004 include CSC 2011; Dybicz 2005; Karabanow 2004; and Slesnick 2007. Moore 2005 and Sanabria 2006 present descriptive reviews focusing exclusively on US-based interventions. While these reviews provide useful analyses and classifications of the literature, their search strategies are often poorly described or limited in scope. Furthermore, they do not contain rigorous evaluation of studies. We identified one review which included interventions for ‘homeless youth’, described as systematic Altena 2010, where studies were reported to have been systematically rated for study quality using a consistent tool. This review is both recent and inclusive of literature in developing countries (language criteria not specified). It searched the following databases: PsycINFO, ERIC, MEDLINE, Cochrane, Google Scholar, EMBASE and CINAHL, for studies conducted 1985--2008. Out of 557 unique search results, twelve studies were included for final evaluation. In comparison, the current systematic review is considerably broader in scope, both in terms of the number of databases searched and the breadth of our search terms. However, to avoid duplication our systematic review takes into account the existence of a Cochrane review on HIV/AIDS prevention with homeless youth Naranbhai 2011, as discussed below. Primary research objectives Furthermore, to explore what can be known about the processes of successful intervention and models of change in this area, and understand how intervention effectiveness may vary in different contexts. This review will also consider potential adverse or unintended outcomes. Some outcomes identified in the literature include negative effects of poorly planned or forced interventions (CSC 2011) and detrimental outcomes frequently documented in association with reintegration of children in non-family care into their families of origin (Thoburn 2009). A possible adverse outcome that may, however, not easily be captured in study evaluations is an increase in street-connected children and young people's mistrust of adults in the context of interventions that may be ad-hoc and short-lived due to lack of funding and other structural support. Study designs that do not provide genuine opportunities for children and young people's participation throughout the research process are most likely to fail in assessing the full range of outcomes of an intervention (Panter-Brick 2002; Slesnick 2007). Interventions targeting outcomes for street-connected children and young people have used a variety of approaches and designs. We will include randomised controlled trials (RCTs), clinical controlled trials (CCTs), controlled before-and-after trials (CBA), interrupted time-series studies (ITS) and quasi-randomised trials. With quasi-randomised trials we refer to studies which allocate the children and young people to treatment/control conditions depending on methods determined as not truly randomised, for example, on their date of birth or the day of the month they enter the intervention site. Where retrieved studies include other nonrandomised designs, such as regression discontinuity designs, the aim will be to include them where it is possible to access appropriate methodological input. Even though we do not aim to synthesise papers discussing the needs and issues of street-connected children and young people and best practice recommendations, we aim to use such literature in order to identify possible explanatory variables that function as mediating or moderating variables in the relationship between the intervention and the outcome of the intervention. We will not include qualitative data in our outcomes synthesis. However, we used qualitative intervention evaluations in order to design the logic model and will continue developing the logic model with the help of qualitative data and the identified included studies in the progress of the review. We will also use qualitative data, including sibling or companion studies of included quantitative studies, to illuminate the impact of context and also mechanisms of change and any process factors. We will not conduct separate searches for qualitative literature, other than for companion studies of included studies and those needed to highlight any particular questions arising in relation to context, mechanisms, and process, etc., according to themes outlined in the logic models. The best way to locate these studies will be to retrieve them from the list of references or from studies citing the study. We will include both elements in the search. In addition, we plan to contact authors directly, requesting information on companion studies. We aim to include all studies focussing on street-connected children and young people between the ages of 0 and 24 years (inclusive), as consistent with the United Nations' (UN) definition of youth as including those aged 15 to 24, regardless of location, reason for street connectedness or gender. Research participants include: street-connected children and young people, their families/carers, professionals working with children, young people and their families, the police, and employers. Street-connected children and young people, and possibly their families/carers will be the intervention recipients. Families and carers are included as potential intervention recipients, firstly because street-connected children and young people remain members of families and also because some interventions (such as conditional cash transfers) might be targeted at families to promote school attendance, literacy, and reintegration of the children. However, we will exclude any studies that do not report separate outcomes data on street-connected children and young people in the context of systemic interventions. Families/carers, the community, professionals, and employers may also be involved in the delivery of interventions. Families/carers, the community, employers, and professionals will be an important part of the ‘input’ component of the intervention to the extent that they are needed to support the intervention and are part of it. Our definition of professionals and community will include NGOs, faith-based organisations, orphanages, social workers, and police. For the purposes of this review we define street-connected children as in Description of the intervention above: “Children and young people may live and work on the street or in public spaces, work on the street and return to family homes or hostels at night, or a combination of these at different time periods. For the most part, they experience complex social and economic circumstances that ‘defy easy definition’ (CSC 2011). Current thinking sees this process as nonlinear, with many street-connected children and young people transitioning off the streets, more than once, with this also, a non-linear process”. We will include any type of intervention including behavioural, social, policy, structural, or other interventions explicitly aimed at reducing risky sexual activity and substance misuse. Interventions may be delivered to individuals, families, small groups or entire communities. Furthermore, recognising the complexity of the issues facing many street-connected young people, there has been a developing focus on multifaced interventions that incorporate a range of approaches including housing, education, training and health (De Benitez 2008). For this review, the included studies require a comparator; either groups who do not receive an intervention, who receive standard practice interventions, or who receive a different type of intervention. Where relevant, we will also examine the relative effects of different intervention components. Since a recent Cochrane review and a systematic review conducted for the WHO have evaluated AIDS and HIV as target outcomes (Naranbhai 2011; Ross 2006) we will not include AIDS and HIV risks as outcome variables. However, we will assess to what degree the included studies of these reviews overlap with our scope/population and if relevant, we will consider the trends in the results of these reviews when interpreting the results of our review. The primary outcomes will be inclusion and reintegration (reintegration by the above definition does not mean returning children to situations from which they may have escaped). We will include intervention studies if they aim to achieve any one of the listed primary or secondary outcomes, or both. Secondary objectives may be particularly relevant where interventions are administered within an existing service setting. A cursory glance at the evidence we obtained from our preliminary searches seems to indicate that there are not many eligible studies; a requirement of including only studies that aim to achieve all of our stated outcomes would probably result in a very small number of eligible studies, or none. Process Measures We will extract measures relating to the process of implementing an intervention and intervention approaches. We will also extract information consistent with the characteristics listed in the logic model in order to develop an explanatory framework. We will include a descriptive map of all studies considered for eligibility for inclusion in the review, in order to present as fully as possible a description of the existing evidence base in this topic. We will include this as adjunctive to the main review in the interests of completeness of data, rather than being used as a tool for narrowing the review focus. We have worked with information specialists from Campbell's International Development Co-ordinating Group and the Cochrane Musculoskeletal Group to develop a search strategy. We will use the following search strategy in MEDLINE: Database: Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations and Ovid MEDLINE(R) <1948 to Present> Search Strategy: ------------------------------------------------------------------------------------------ 1 “Homeless Youth”/ or (homeless$ adj2 (child$ or youth$ or young or teen$ or adolescen$)).tw 2 “Runaway Behavior”/ 3 runaway$.tw. 4 (street adj4 kids).tw. 5 (street adj4 youth).tw. 6 Child, Abandoned/ 7 abandoned child$.tw. 8 Child, Orphaned/ 9 (orphan$ adj3 child$).tw. 10 Child, Unwanted/ 11 (unwanted adj4 child$).tw. 12 (street adj4 child$).tw. 13 Criancas de rua.tw. 14 Meninos de rua.tw. 15 (street adj3 urchins).tw. 16 (Pavement adj3 dweller$).tw. 17 (railway adj2 children).tw. 18 (unaccompanied adj4 (refugee$ or migrant$)).tw. 19 (unaccompanied adj4 minor$).tw. 20 Tikyan.tw. 21 (niños adj3 calle).tw 22 (ninos adj3 calle).tw 23 (enfants adj3 rue).tw 24 (jeunes adj3 rues).tw 25 or/1-24 26 children.tw. 27 Adolescent/ 28 teenager.tw. 29 baby.tw. 30 adolescent.tw. 31 adolescents.tw. 32 adolescence.tw. 33 teen$.tw. 34 babies.mp. 35 toddler.mp. 36 toddlers.mp. 37 youngster.mp. 38 youngsters.mp. 39 young people.mp.