Original article

Health and social problems of street children

Yemane Beyene, Yemane Berhane

Abstract: As there is no documented information on street children in Ethiopia, a cross sectional

survey was conducted in Nazareth town, South Eastern Ethiopia, in December 1994. The purpose
of the survey was to describe the health and social problems of the street children. By means of a
systematic sampling method, based on a census registration, 597 subjects, 526(88.1%) males and
71(11.9%) females, were recruited for the study. Four hundred and one (67.2%) of the children
reported eating at least twice daily. One hundred and six (14.6%) of the children reported the use
of habit forming substances. Three hundred and sixty eight (61.6%) of the children reported an
illness during the survey. The major health complaints were abdominal pain, cough and headache.
Substance use, arrest by police, current sexual activity and STDs were reported more frequently
among the "off" the street children. Improving access to existing social services and exploration of
possibilities to rejoin the street children with their families are recommended.[Ethiop. J. Health Dev.
1998;12(1):51-55]

Introduction
Many factors are known to have contributed to the health problems of street/homeless persons.
The list includes: exposure to adverse weather, crime, overcrowding in shelters, unusual sleeping
accommodations, poor hygiene and nutritional status, alcoholism and drug abuse. Due to those
exposures homeless children were reported to have high rates of developmental, emotional and
nutritional problems(1-5).
Because of the many problems they encountered at early ages, street children are bound to remain
disadvantaged throughout their life-time due to lack of life experience in an organized family. They
also lack basic education and vocational training opportunities. Girls in particular are also exposed
to sexual exploitation, rape, and prostitution(6,7).
Access to health care is very much limited for homeless families. There is no real opportunity for
the street children to develop an ongoing relationship with a health care provider since they are
highly mobile and health is a lower priority, as they struggle to meet the daily demands for food and
shelter.
They may only get episodic and fragmented health care when they are confronted with an acute
and severe illness(4,8).
The complex confluence of family, economic, and social problems have made the task of
intervention seem overwhelming. However, there are encouraging reports of interventions on
similarly high risk and impoverished families which showed that comprehensive interventions, well
oriented to the problems of the children, can significantly improve the situation(9-12).
Though the magnitude of the problem is not fully researched in Ethiopia, it is believed that the
problem is ever growing as elsewhere in the developing world(13,14). Therefore, this study was
carried out with the purpose of describing the health and social situations of street children in the
Ethiopian context with the hope that it may facilitate the planning and implementation of effective
interventions to improve the life of street children.
______________________________________
From the Department of Community Health, Faculty of Medicine, P.O. Box 9086 Addis Ababa
University

Methods
The study utilized a cross-sectional, descriptive design based on the census registration to assess
the social and health problems of street children in Nazareth town in December 1994. The town is
 Health and social problems of street children 2
------------------------------------------------------------
located 100 kilometres south east of Addis Ababa, the capital of Ethiopia, and has an estimated
population of 150,000. The town is a major transit location for the traffic coming from Asab and
Djibouti Sea Ports.
A sample of 600 street children was required for the study based on the following conservative
assumptions: a 50% prevalence of health problems, with 95% certainty and an expected difference
of ±4 prevalence between the sample and the total population. The study population was identified
during a census registration and study subjects enrolled systematically after a random start. The
census was conducted in one night with the help of the local Ministry of Labour and Social
Affairs(MOLSA) staff and the leaders of the street children. A total of 5,138 children were
registered in the census. All street children up to the age of 18 years were considered for inclusion
in the study.
A uniform and pretested questionnaire was used to collect data from the street children on their
health and social problems by trained health assistants. The interviews were conducted for one week
in December 1994 at the health centre located in the town. Supervision was made by a nurse
coordinator and the principal investigator who is a physician. A social worker from the local
MOLSA office helped in building good rapport with the street children. The social worker has been
in contact with the street children previously and was familiar to most of the children.
An informed consent was obtained from all study subjects. Children who reported health problems
were given free treatment depending on the nature of their illness at the health centre and the local
hospital. Lost work hours were also compensated.
Data were processed using Epi Info statistical package. Frequencies, rates, rate ratios with 95%
confidence intervals were used to present the results.

Result
A total of 597 subjects, of which 526(88.1%) were males, were enrolled for the study. The
dominant age group was 10-14 years accounting for 52.8% of the study population. The age ranges
from 5 to 18 years, with a mean age of 12.9(SD= 3.16). Three hundred and forty two (57.3%) of
the children had four or more siblings. Four hundred and forty seven (74.9%) of the children had a
birth order below three. One hundred and eighty three (30.7%) were separated from their families
in early childhood, before their 4th birthday. Three hundred and sixty six (61.3%) of the street
children had primary school education.
Table 1: Living conditions of street children, Nazareth, 1994.
Variables “On” street “off” street X2 P-value
Body washing

Never Wash 227 205

Once/15 Days 82
42
Occasionally 17 24 10.4 .006
.Cloth Washing

Wash 274 120

Don’t wash 52 151 102.5 .0001

Income (Birr)/day

0-0.99 123

1-1.99 29

2-2.99 62

3-3.99 50

4-4.99 16

≥5.00 46 8 136.9 .001

Meals

As Available 103
30
 Health and social problems of street children 3
------------------------------------------------------------
Once/day 53
10
Twice/day 15 118

Three/day 155 113 149.7 .001

Financial Saving

Yes 26 16

No 300 255 0.68 .4

The street children were classified during analysis into two groups as "on" and "off" street children.
Three hundred and twenty six (54.6%) were "on" the street type and the rest 271(45.4%) were "off"
the street type. Children "on" the street had a house to sleep in at night whereas "off" the street
children are completely homeless and had no contact with their families.
Two hundred three(34%) of the children reported that they do not have the habit of washing their
clothes at all. One hundred threety three (22.3%) of the children reported that they eat meals
according to their income(as available), 63(10.6%) eat once daily, and the rest 401(67.2%) reported
to eat at least twice daily. Only very few, 42 (7%), of the children save money from whatever they
earned for emergency purposes. Washing habits and earnings were significantly better among the
"on" the street children. But children "off" the street reported to have been eating more meals per
day compared to the "on" the street children (Table 1).

Table 2: Substance use and sexual practice among street children, Nazareth, 1994.
Variables On” street“ “off Street Or (95% CI)
Substance Use

Yes 21 85 1.00
No 305 186 0.15(0.09,0.26)
Police Arrest

Yes 4 36 1.00
No 322 235 0.08(0.02,0.24)
Ever had Sexual Intercourse 11 82 1.00
Yes 315 189 0.08(0.04,0.16)
No

History of STD 9 27 1.00

Yes 317 244 0.26(0.11,0.58)
No 21 85 1.00

Four hundred ninty one (82.2%) of the children reported that they never used any of the three of
the habit forming substances (cigarette, alcohol and chat). The rest 106 (17.8%) reported the use of
at least one of these substances. Fourty(6.7%) reported that they were arrested by the police at least
once. The majority(84.4%) of the children reported that they are not yet sexually active while 15.6%
of them reported that they had sexual intercourse already. Few (1%) said they started sexual
intercourse when they were between the ages of 5 and 9 years. Sexually transmitted diseases were
reported by 36(38.7%) of the sexually active street children. Substance use, arrest by police, sexual
experience, and STDs were reported less frequently among the "on" the street children, the
differences were statistically significant at P<0.05.

Three hundred and sixty eight (61.6%) of the street children reported health problems during the
survey time. Abdominal pain, cough and chest pain, eye and ear problems, headache, and leg ulcer
were the major complaints (Table 3). Children over ten years of age were more likely to be ill than
the younger children, a statistically significant finding. All other variables studied which include:
number of sibling, child's education, status of parents(alive or dead), family support, age of the child
at leaving the family and current school attendance did not show statistically significant association
with current illness (Table 4).
 Health and social problems of street children 4
------------------------------------------------------------

Table 3: Frequency of reported health problems among street children in Nazareth, 1994.
Frequency Percent
No complaint 229 38.4
Abdominal Pain 95 15.9
Cough & Chest Pain 59 9.9
Headache 53 8.9
Leg Ulcer 49 8.2
Eye & Ear Problems 38 6.4
Fever 34 5.7
STDs 16 2.7
Others 24 4.0
Total 597 100%

Discussion
This study utilized a probability sampling technique to select the study subjects, trained
interviewers who used a standard and pretested questionnaire, and applied a strong supervision
system. Therefore the design and implementation of the study are believed to minimize bias, which
could possibly distort the results.
Although most children claimed to eat at least twice daily, the safety of the food is believed to be
very poor. Some of the children salvage their food from a public garbage basket. The feeding habit
of the children, in general, is believed to have exposed them to various kinds of food borne infectious
diseases(8).
Personal hygiene was observed to be very poor which could be mainly due to the unavailability or
the less access of the facilities for washing, which is yet another reflection of their standard of living.
Substance use (16.8%) in this population seems to be low, when considering their exposure to such
environment and the lack of any parental supervision and guidance. However, it was higher than
the figure reported for high school students in Addis Ababa which was 9.2%(15). It is also worth
noting that those who reported the use of substances do so when they were very young, which may
put them at a higher risk of developing complications from the use of these substances and may
make them suffer a high degree of dependence. Substance use would also increase their demand for
more money, which in turn may force them to get involved in anti-social activities such as robbery.

Table 4: Bivariate analysis of selected factors affecting the health of street children, Nazareth, 1994.
Variable ILL Not ILL OR(95%C)

Age
5-9 42 42 1.00
10-14 199 116 1.72(1.03,2.87)
>14 127 71 1.79(1.03,3.10)
Siblings number

0-3 164 191 1.00

4-7 190 119 1.86(1.35,2.57)
>7 14 19 0.86(0.39,1.86)
Child’s Education

Illiterate 127 37 1.00

Read and Write 27 13 0.61(0.27,1.38)
Primary 199 167 0.35(0.22,0.54)
Secondary 15 11 0.40(0.16,1.02)
Alive Parents

Both parents 234 157 1.00

Father alive 23 16 0.96(0.47,1.98)
Mother alive 70 36 1.30(0.81,2.10)
 Health and social problems of street children 5
------------------------------------------------------------
Both Dead 32 15 1.43(0.72,2.87)
Don’t Know 12 3 2.6890.69,12.18)
amily Support

Yes 47 42 1.00
No 321 187 0.65(0.40,1.05)
ge when leaving family

0-4 114 69 1.00

5-9 73 56 0.79(0.49,1.28)
10-14 160 86 1.13(0.74,1.71)
15-19 21 18 0.71(0.33,1.50)
urrent school Attendance

Yes 69 40 0.92(0.58,1.44)
No 299 189 1.00

Though it may be an under estimate, 15.6% of the surveyed children reported that they have had
sexual intercourse already. The risk of acquiring STDs, particularly HIV, and unwanted pregnancy
with their complications are eminent since preventive behaviours are generally lacking.
Higher rates of substance use, arrest by police and sexually transmitted diseases are observed
among the "off" street children. This could be the reflection of the degree to which the children
are affected from the loss of family and cultural values. The 6.7% reported rate of arrest by the
police was comparable to a study in Brazil which was 4% and very low as compared to an Indian
study which was 39%(16).
Over 60% of the street children reported at least one symptom of a disease during the time of the
survey. Considering their exposure to the harsh environment in the street, it may not be surprising,
but could be seen as one of the manifestations of the agony of street life. The major health
complaints were almost similar to what have been reported elsewhere(16), and are related more or
less to their living conditions. This was substantiated by the fact that the "off" the street children
were the ones who reported health problems more than the "on" the street children. It is worth noting
that although the health care facilities are readily available physically in the town, the street
children's access to them is limited by their status and economic constraints.
In conclusion, the findings indicated that the street children are exposed to complex social and
health problems- for example, they suffer from lack of suitable shelter, use of substances and lack
of basic health services. Therefore, comprehensive health and social interventions need to be
designed and implemented in order to improve the conditions of the children. Interventions may
include: making the existing social services accessible to them, exploring possibilities to rehabilitate
and rejoin them with their families, and exploring possibilities for providing street-based health
education in a way that is acceptable to them.
 Health and social problems of street children 6

---------------------------------------------------
---------
Acknowledgement
The study is financially supported by the International Development Research
CentreCanada(IDRC). We also gratefully acknowledge the material support received
from the Department of Community Health, Faculty of Medicine, Addis Ababa
University. Our heart-felt thanks is due to the local Ministry of Labour and Social
Affairs office in Nazareth.
 Health and social problems of street children 7
------------------------------------------------------------
References
1. Bonnie TZ, Kennet BW, and Howard EF. Emotional and behavioral problems and severe academic delays among
sheltered homeless children in Los Angeles county. American Journal Of Public Health 1994;84(2):260-63.
2. Richard PV, Lilian G, Mary S, and Jana L. Health care for the homeless. American Family Physician
1994;49(1):139-45.
3. US public health service. National ambulatory medical care survey. Background and methodology, vital and health
statistics 1979;2(61).
4. Alperstein G, Rappaport C, and Flanigan JM. Health problems of homeless children in New York city. American
Journal Of Public Health 1988;78:1232-33.
5. Janet W. and Edna M. The depression of homeless children: A focus for nursing intervention. Comprehensive
Pediatric Nursing 1987;14:17-19.
6. Brickner PW. Scanalan BC. Conanan B.Elvy A. McAdam J. and Scharer LK. et al. Homeless Persons and Health
Care. Annals of Internal Medicine 1986;104:405-9.
7. Ministry Of Labour and Social Affairs and Italian Cooperation for Rehabilitation and Prevention Project for
Street Children. Addis Ababa. 1992.
8. Gross TP. and Rosenberg ML. Shelters for the battered women and their children: An under recognized source of
communicable disease transmission. American Journal of Public Health 1987;77:1198-1201.
9. David LW, R. Burciaga, Toshi H, and Albert S. Health of homeless children and housed, poor children.
Pediatrics 1990;86(6):858-65.
10. Chamberlain RW. Developmental assessment and early intervention programs for young children: Lessons learned
from longitudinal research. Pediatrics Rev. 1987;8:237-248.
11. Weikart DP, Schweinhart LJ. Young children grow up: The effects of perry school program on youths through
age 15. Yosilanti, MI: High scope press;1980 monograph series 7.
12. Olds DL. Henderson CR. Chamberlain R. Talelbaum R. Preventing child abuse and neglect: A randomized trial
of nurse home visitation. pediatrics. 1986;78:65-78.
13. Tacon P. Protection, Respect, and Opportunity for the street Children of Ethiopia. Unpublished report to UNICEF,
Ethiopia, 1992.
14. UNICEF. The state of the world children; London 1992.
15. Kebede D. and Ketsela T. Precursors of Atherosclerosis and Hypertensive Diseases Among Adolescents in Addis
Ababa, Ethiopia. Bull. WHO, 1993;71(6):787-794.
16. Sheela P. Street children, hotel boys and children of pavement dwellers and construction workers in Bombay:
How they meet their daily needs. Environment and urbanization 1990;2:9-25