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Module 3
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Contents
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Introduction.
Lesson 1: Types of psychoactive substances.
1.1 Psychoactive substances street children may use.
1.2 Other substances that street children use.
1.3 Methods of using substances.
I .earning aclivily.
Lesson 2: Effects of substances on the street child.
2.1 Effects of substances.
2.2 Polysubstance use.
2.3 Special considerations.
2.4 The role of psychoactive substance in the lives of street children.
Learning activity.
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Lesson 3: Patterns of psychoactive substance use and their consequences.
3.1
Patterns of substance use.
3.2 Consequences for the individual street child.
3.3 Consequences for the family and community.
Learning activity.
Lesson 4: Applying the Modified Social Stress Model in substance use.
4.1
Stress.
4.2
Normalization of behaviour and situations.
4.3
Effects of behaviour and situations: the experience of substance use.
4.4
Attachments.
4.5
Skills.
4.6
Resources.
Learning Activity.
Bibliography and further reading.
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Introduction
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Studies have found that between 25% and 90% of street children use psychoactive substances of
some kind. The word ‘substance’ describes any psychoactive material which when consumed affects
the way people feel, think, see, taste, smell, hear or behave. A psychoactive substance can be a
medicine or an industrial product, such as glue. Some substances are legal such as approved
medicines, alcohol and cigarettes, and others are illegal, such as heroin and cannabis. Each country
has its own laws about substances. The percentage of substance users among street children varies
greatly depending on the region, gender and age.
To understand substance use a framework called the Modified Social Stress Model* is used. The
model explains the complex relationship between factors that affect the onset and continuation of
substance use. The model suggests that positive and negative aspects of six vulnerability/protcctive
factors affect the risk of substance use. These are stress, normalization of behaviour and situations
(acceptance) of substance use in the community, effects of behaviour and situations, attachments,
skills and resources.
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This module provides basic information about substances and health consequences of substance use.
It introduces the Modified Social Stress Model as a useful way of understanding substance use
among street children.
Learning objectives
After reading this module and participating in the learning activities you should be able to:
Name the types of substances street children use and the ways in which street children
take them.
List the common substances used by street children in your community.
Describe the effects of substances.
Describe the patterns and consequences of substance use.
List factors that make substance use more likely or less likely according to the
Modified Social Stress Model.
* This model of substance use is based on the Social Stress Model developed by Rhodes and .Jason (19X8). WHO programme on
Substance Abuse (PSA) modified the framework to include the effects of substances, the personal response of the individual to the
substances, and additional environmental, social, and cultural variables. It is only one model and may not be applicable to other areas.
In both Phases I and II of the WIIO/PSA Street Children Project, sites found the model Io be useful in better iindcistanding and
responding to substance use and other health issues among street children.
Module
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Lesson 1 - Types of psychoactive substances
1.1 Psychoactive substances street children may use.
The types of psychoactive substances street children use can be many and varied and it may be
difficult to determine what substances they are using. Substances which are sold on the market can
be identified by their generic name. This is the standard name used through out the world. However
some substances arc marketed under various names known as trade names and others have ‘street
names1, for example, diazepan is the generic name while valium is a trade name. Diacetlymorphine
is a generic name for heroin and ‘brown sugar’ or ‘smack’ are some of the names it is called by on
the streets. It is important for the street educator to know the general categories of substances and
the effects that substances can have on a street child. The following examples of substances in their
general categories may not be the ones used in your country, they arc merely illustrative.
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Alcohol
Alcohol is a depressant which inhibits or decreases some aspects of
central nervous system activity (ie., activity of the brain, spinal cord, and
some major nerves).
Substances containing alcohol include
the following: wine, beer, spirits,
home-brew, some medicinal tonics
and syrups (c.g. cough syrups), some
toiletries and industrial products.
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Nicotine
Nicotine is a stimulant; that is any substance which
activates, enhances or increases central nervous
system activity. Nicotine is found in the
following substances:
cigarettes, cigars, pipe tobacco, chewed
tobacco, snuff, nicotine gum, spray, skin
patches.
Most cigarettes have about 1-2 milligrams of nicotine.
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Opioids
Substances in this group may act as analgesics (they relieve
physical pain) and depressants. They may be synthetic or
made from opium poppies (opiates). The following
substances are examples of opioids:
opiates: codeine (such as in some cough mixtures),
heroin, morphine, opium
synthetic opioids: buprenorphine hydrochloride
(Tcmgesic), methadone (Physcptone), pethidine.
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Hallucinogens
I lallucinogcnic substances can alter a person's mood, the way the person perceives his or
her surroundings and the way the person experiences his or her own body. There arc
many different types of hallucinogens, some of which are chemically produced and
others which are naturally occurring.
LSD (Lysergic Acid Diethylamide): in its pure state LSD is a white,
odourless powder. It is usually mixed with a lot of other
ingredients. It is often put into capsules, liquids, tablets, and as
small spots on absorbent paper.
mescaline: made from the pulp of the peyote cactus.
psilocybin mushrooms: Psilocybin is the hallucinogen found in some mushrooms. Il is usually
made available as dried mushrooms.
PCP (phencyclidine): this substance was used as an animal tranquilliser.
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Cannabis
The cannabis plant grows in many parts of the world. Preparations
containing different concentrations of cannabis arc consumed.
marijuana: the leaves and flowers of the marijuana or
hemp plant.
hashish (oil and resin): these forms of cannabis are made from the resin of the
Powering heads of the plant
tablets containing THC (Tetrahydrocannabinol, the main active ingredient in cannabis)
O Hypnosedatives
The drugs in this group are made synthetically and do not occur
naturally. There are a large number of different drugs in this
group. All arc slightly different, but all subdue the body's
nervous system,
benzodiazepines: c.g. alprazolam (Xanax), diazepam (Valium),
llunihazipam (Rohypnol), oxazepam (Serepax), temazepam
(Nonnison)
barbiturates: pentobarbital.
Other sedatives, such as chloral hydrate and methaqualone (Mandrax)
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1.2 Other substances that street children use.
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It has been noted through the WHO project on substance use among street children that street
children claim that inhaling through a wet carbon paper, inhaling vapour produced by a mixture of
fibre matting and boiling toothpaste, inhaling fumes from burning insects, and inhalation of raw
sewerage can produce desired effects. Efforts should be made to learn about the types of substances
that are being used by the street children locally. This information could be obtained from specialists
in your community, such as pharmacists and medical personnel. The specialists may provide samples
of the products so that you are familiar with them.
1.3 Methods of using substances.
Substances can be used in many different ways. They may be:
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Chewed, swallowed or dissolved slowly in the mouth.
Placed on a mucous membrane (such as inside the anus or vagina, or nose, or under the eyelid).
Rubbed into the skin.
Injected under the skin or into a vein or muscle with a needle.
Smoked or inhaled through the mouth or nose, or inhaled by placing a bag over the head known
as bagging.
The way the substance is taken also inlluences how fast the substance reaches the brain or other
organs. Injecting a substance is especially dangerous because of the risks of infection that are carried
through the blood (blood borne). In particular, sharing needles or other injecting equipment and the
way the substance is prepared can spread HIV (the virus that causes AIDS), hepatitis B and C, and
other infections because of contamination with infected blood.
Substances can be inhaled
through the mouth or nose.
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Module 3 - I ndei slniHliii” Subskiiife (
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Learning Activity
1. Substances used by local street children.
List the substances that are used in your area in the table below. Beside each substance write the
slang name that street children use for the substance. In the third column, give the common
methods by which the street children use these substances. In the fourth column, write whether
the substance is legal or illegal in your community. Finally mention how street children obtain
these substances in your area (for safety and confidentiality, avoid using names).
Substance
Slang names
Routes of intake
Legal/lllegal
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Sources of substances
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2. Substances not described on the previous list.
Write down the names of substances whose effects are not known to you but are used by street
children that you work with. Contact local reliable medical service providers to complete the
outline below and overleaf.
Type of substance:
Common reactions:
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3. Substance preference.
Do different subgroups of street children prefer certain substances?
• Younger children (specify age).
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• Girls.
• Boys.
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Notes
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Moduli* 3 - I ikIci sfiiiidiii” Substance I
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Lesson 2 - Effects of substances on the
street child
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2.1 Effects of substances.
Any substance can be harmful to a human body if taken in large enough doses, too frequently or in
an impure form. The health effects of substances can occur immediately or in the long-term. The
effects are influenced by the dose, the method of administration as well as whether the substance is
used with another drug. The long-term effects often take a long time to appear and are usually due
to damage of body organs. Be aware that some signs attributed to substance use may be due to other
conditions, e.g. poor concentration can be a sign of glue sniffing, but it could also be caused by stress
or worry about a life event, about pregnancy, or as a result of head injury. Effects of individual
substances arc presented below:
Alcohol.
The effects of alcohol will vary from person to person. Children, young people and women are
usually more affected by alcohol than adult men because they tend to have lower body weights,
smaller livers, and a higher proportion of fat to muscle. This leads to faster absorption of alcohol in
the body.
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Immediate effects: These include drowsiness, uninhibited actions (a person is more likely to
do things that normally he or she would stop himself/ herself from doing), loss of physical
coordination, unclear vision, slurred speech, making poor decisions or impairment of memory.
Excessive drinking over a short period of time can cause headache, nausea, vomiting, coma
and death.
Long-term effects: Drinking large amounts of alcohol regularly over a long period of time can
cause loss of appetite, vitamin deficiency, skin problems, depression, loss of sexual drive, liver
damage, heart ailments, nerve and brain damage or loss of memory.
Associated health risks: These occur when alcohol is taken with
other substances or drugs. Taking alcohol with drugs that depress the
body’s systems, such as hypnosedatives or cannabis, can increase loss
of judgement and loss of physical coordination. Combination with
hypnosedatives can lead to coma, respiratory depression (person stops
breathing) and death.
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Nicotine.
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Nicotine, the active substance found in
tobacco is addictive in nature. Once a
street child starts using tobacco, they are
likely to continue using it for a long time.
® Immediate effects: A person feels alert immediately
after using tobacco, and then feels more relaxed a few minutes
later. There is also an increase in pulse rate, a temporary rise in
blood pressure, dizziness, nausea and reduced appetite.
© Long-term effects: These effects may be due to the nicotine or
the form in which it is taken. Heart and lung disease, blockage of arteries (peripheral vascular
disease), high blood pressure, breathing difficulty, cancer of the lung (with cigarette smoking)
and cancers of the mouth (with pipe smoking and tobacco chewing) may occur.
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Opioids.
Substances in this group may act as pain
killers and/or depressants. Some arc used as
medicines while others are illegal. Opium,
morphine, codeine (constituent of some
cough mixtures) and heroin are
derived from opium poppies
directly or through chemical
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processing (opiates), while
buprenorphine (Tcmgcsic), methadone
(Physcptone) and pethidine are made
synthetically (opioids).
Immediate effects: Opioids often produce a detached and dreamy feeling, sleepiness,
reduction in the size of the pupil of the eye, nausea, vomiting and constipation. Overdose leads
to unconsciousness, respiratory depression (failure to breathe) and death.
-n Long-term effects: The main danger is the development of dependence and the chance of
overdose that can cause death. Tolerance and dependence can develop quickly.
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Associated health risks: Opioids may be injected into the body. Injecting the substances with
a needle that is not sterile or is shared between users can transmit blood borne infections
including HIV, hepatitis B and C, and may result in septicemia (infection in blood).
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Hallucinogens.
These substances can alter a person’s mood, the way the person perceives his or
her surroundings and experiences his or her own body. A user may also
hallucinate (perceive something that does not exist).
Immediate effects: The immediate effects are those of
change in perception and in the awareness of things
happening inside and outside one’s body. Things may look, smell, sound, taste, or feel
different c.g. seeing colours, lights, pictures. ‘Bad trips' may also occur. The term refers to
unpleasant and disturbing feelings e.g. panic, fear, anxiety, confusion and alteration in the
sense of reality, fhc nature of the experience is partly determined by the setting in which the
hallucinogens arc taken. Unintentional injuries and suicide may happen under the influence
of hallucinogens.
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Long-term effects: Many users report getting the experiences first obtained under the
inllucnce of substance, days or even months after they have stopped taking the substances.
These experiences arc called ‘Hash backs’. Regular use of hallucinogens can decrease a
user’s memory and concentration and can result in depression and other mental health
problems. PCP is particularly likely to cause lasting mental health problems.
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Cannabis.
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Cannabis may make
Large doses can
hallucinogens.
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® Immediate effects: feelings of well being,
relaxation, loss of inhibitions, loss of motor
coor ination and loss of concentration. There may
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causes any significant long !asth’gd|™al'hpa|'oblcnVRnnal|'S °“asi<,nall>'in smal1 quantities
chances of dependency, impairment „f memorv nd o™±Z? "" ’ '0"B
increases
problems such as schizophrenia.
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concentration and may worsen mental
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Hypnosedatives.
( are a large number of different drugs in this group
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calming properties. There
" Immediate effects:: all substances in this
group cause effects similar to alcohol. They
slow down a person’s thinking and
movements and decrease the ability l(>
concentrate. They cause ‘hangovers’, or
pioblems such as shirred speech,
sleepiness and lack of coordination after the
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health risks because the substance is not broken do RePeatedk d]oses cause other associated
injuries and suicide can occur.
Wn (metab°hsed) quickly. Unintentional
heavy use can result in problems with mem
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dependence’ and continued
coordination. Convulsions and delirium tan
l° lcain’ and Problcms with
substance is withdrawn.
(
acute6 C0nfusi0Iia
confusional' state) can occur when the
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Module 3
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Stimulants.
Stimulants enhance or increase central nervous system activity. They are
popular because they make people feel energetic, self-confident and they
decrease the feeling of hunger. They are often used to reduce weight
and help people stay awake for work. If too much of the stimulant is
taken, the person may become anxious, irritable, suspicious, panicky,
and/or threatening to others.
Immediate effects: caffeine in coffee and teas spreads quickly
through the body and makes a person feel awake, foo much of caffeine can cause an increase
in heart beat, anxiety and upset stomach. The effects of cocaine and
amphetamines are similar except that the effects of cocaine last for less time.
These arc excitement, decreased need for sleep and food. High doses can
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cause anxiety, panic, high blood pressure, convulsions and aggression. With
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crack (cocaine which is smoked) a person usually experiences a brief
intense feeling of intoxication and an exaggerated feeling of confidence.
The mood then quickly changes to a low feeling and may prompt the
person to repeat the dose. Overdose is commoner with crack
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than with other forms of cocaine.
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Long-term effects: coffee and tea may cause anxiety,
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depression, stomach upset and difficulty in sleeping. Longterm use of amphetamine and cocaine can cause dependence, inability to sleep, irritability, and
mental health problems such as feelings of suspiciousness and hallucinations. Similarly, heavy
use of khat can result in dependence and physical and mental problems.
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Inhalants.
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Like alcohol, they make a person uninhibited at
first and drowsy later.
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® Immediate effects: Feelings of
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happiness, relaxation, sleepiness,
poor muscle coordination,
slurred speech, irritability and
anxiety. Hallucinations and
fils can occur with heavy use.
The most immediate danger to the user is of‘sudden
sniffing death’. Death could also occur as a result of suffocation.
Long-term effects: Regular long-term use may lead to nose
bleeds, rashes around the mouth and nose, loss of appetite and
lack of motivation. Some of the solvents are toxic to the liver,
kidney, heart and brain.
Module '
I ndci sliiixlino StihsLincc I
\ in<hih Si r cd ( hildi
Other psychoactive substances.
Some substances do not belong in any of the above mentioned categories.
Examples are:
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Kava: is used in the South Pacific for social
and ceremonial purposes. It causes mild
sedation and feeling of well being. Heavy
use can cause dependence and medical problems.
Betel nut: is often chewed in parts of Asia and the Pacific. Regular use can cause dependent
and diseases of the mouth, including cancer.
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2.2 Polysubstance use.
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at the same or different times. In
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hallucinogens and inhalants. Combined use of substan
°pi10lds’ stimulants, hypnosedatives,
the child is using more difficult In addit^Ti c
tle assessmcilt of substances tha
witlidrawab Combination of substan^ m Xe tl^Tof ' ’h
u °f detoxif-hon or
accidents, death, violence and suicide.
R f overdose and thus the chances of
2.3 Special considerations.
These include mahubiti^ rn^md Sd. aX^Zncy’
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Malnutrition.
Although alcohol has calories and provides energy it can also r
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prevent the absorption of
takin* stances
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this can lead to malnutrition.
vmmren use substances to relieve hunger and
Mental health.
depressed. A serious st^Zd'eprVssZcan'atobe 1°" 'n
alcohol use.
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Wh° 316 a’ready
11 als° be a co^equence of long-term excessive
me"tal llCalh problems Sl|ch ;
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as depression,
with suicide being a
k. They may also worsen a pre-existing mental disorder
such
-1 as schizophrenia.
• Young people who use substances such
from their tension. This limits'ZdXelopmentof otl
eXperience and get rclicf
For
St,'ate8ics:
for example the use of hypnosedatives can helpstreet'children'fTr"
do not change the cause of the street child’s anxiety
anX1°US’ but they
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Pregnancy.
® Regular drinking of even small amounts of alcohol during pregnancy can damage the health
of both the mother and the foetus. Heavy drinking can lead to miscarriage or foetal alcohol
syndrome (slowed growth and mental disabilities in the baby). Alcohol can be passed to the
infant through breast milk.
• Smoking during pregnancy can reduce the amount of oxygen available to the unborn and
may affect the baby’s growth and development before, and after birth. This usually leads to
low birth weight in the baby. Similar problems may accompany the use of cannabis during
pregnancy.
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A mother using opioids, hypnosedatives and stimulants exposes the baby to the substance.
If the pregnant or lactating (breastfeeding) mother stops using these substances suddenly the
baby will experience withdrawal. Amphetamines may lead to miscarriage and cocaine can
cause developmental delays.
• LSD can increase the chance of a miscarriage and complications during pregnancy. Babies
of mothers who use hallucinogens, may be born with physical deformities.
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2.4 The role of psychoactive substances in the lives of street children.
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Even though using psychoactive substances may lead to serious problems, many street children use
them cither because a particular substance adds something to their lives or it temporarily solves a
problem. There is a connection between the problems of life on the street and the effects that
substances sometimes produce.
“After inhaling solvents, you feel the earth quake and that God is above you. Once half of the body
of Rizal appeared as a manananggal (flying witch). After a few hours, you lose your appetite, feel
very weak, tired and sleepy” (edited from a quote from Filipino street boy).
Sonic effects that street children may desire:
Problems on the street
Possible effects of use
Hunger
Lessens hunger pains
Boredom
Adds excitement
Fear
Provides courage
Feelings of shame, depression, hopelessness
Helps to forget these feelings
Lack of medicine and medical care
Self medication
Difficulty falling asleep because of noise and
overcrowding, cold or heat, mosquitoe bites
Produces drowsiness
Being tired from lack of sleep because of noise
or overcrowding
Increases energy to work
Risk of being attacked and abused
Improves alertness
No recreational facilities
Offers entertainment
Social isolation
Provides a sense of connection with other
substance users
Loneliness
Promotes socializing
Physical pain
Relieves physical pain
No money for food
Makes it easier to steal
Often the substances do not produce the effect the street child wants and they leave the child with
even less emotional, financial and health resources than before. Street children in developing
countries who use substances often do not fit the stereotype of an adolescent substance user in the
developed world who tends to be unhappy, insensitive and disrespectful. Young substance users on
the street arc often cheerful, affectionate, and respectful of authority. They do not use substances
because they reject mainstream society, but rather because they have lost their place in it.
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Module 3
I ndei s(:iii(lin)> Snlisl:i
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Learning Activity
1. Effects of substances.
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Ahmad, a 15-year-old street boy is lying on the sidewalk of one of the roads leading to the
market. As you approach him and attract his attention, you notice that his mood is not the same
as usual and in a loud voice, he tells you that “things look different today”. Showing you a
mango in his hand, he says “this too tastes like a piece of chicken”, pointing at a thin broken
branch of a tree, he screams “there is a snake on the tree”. He smiles at you and says he feels
things happening in his body. If Ahmad is under the influence of a substance(s);
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What type of substances could make Ahmad behave in this way?
•
What other immediate effects do you expect to see in him?
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List other risks involved in the use of this type of substance (s):
2. Other substances.
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Lilu, a 16-year-old street girl has been brought to the shelter for street children where you work.
As part of vocational training, girls are taught house keeping, to prepare them for potential
careers as domestic workers. You have given Lilu the responsibility of safe guarding all items
for use in this domestic training course. One afternoon, Lilu appears irritable, anxious and
combative. She tells you that she hears cries of babies while you do not hear anything.
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Given the type of responsibilities Lilu has, what substance do you think she could have taken?
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What other effects do you expect her to experience?
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Hallucinogens and volatile inhalants are the key substances for question one
and two.
3. I’lcnsc respond (o (he (picsHons ns requested below.
a) When alcohol is taken, it provides the much needed calories to street children and contributes
to the prevention of malnutrition. I’rue/I'alse
b) Which of the following statements is false? Circle your answer.
• In many areas street children use more than one substance at the same time.
• The signs that substances may cause in street children could be a result of other health conditions.
• Alcohol prevents the absorption of certain vitamins and nutrients in the body.
• Substance use among street children enhances the ability to develop constructive coping strategies.
4. Think of some of the problems that street children in your area have and which substances
they use to help them solve these problems. For each of the problems that you selected, w hat
are the substances that street children are using to help solve that particular problem?
Problems:
Substances chosen to help solve problem:
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Lesson 3 - Patterns of psychoactive
substance use and their
consequences
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3.1 Patterns of substance use.
Two important factors that determine patterns of substance use in the community are the price an.
availability of the substances. Street children almost always choose the least expensive and mos.
readily available ones, e.g. inhalants such as glue or petrol. If they decide to drink alcohol, they ten.
to pick the cheapest beverage with the highest alcohol content.
Patterns of substance use vary greatly among street children and may change over time. Som
develop a regular pattern of use while others may be quite haphazard. A street child may change h..,
or her pattern of use over time. Use of substances does not mean that he or she will automatical!
progress to using other substances or to use more intensively. Included under patterns of substanc
use are experimental, functional and harmful use, abuse and dependant use. Functional am.
experimental use relate to the issues of adolescence and survival on the street as outlined in lilt
previous modules. Explained below are intoxication, harmful and dependent use.
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Intoxication
Intoxication is a temporary state that follows the use of one or more substances resulting itiW
change in the person’s alertness, thinking, perceptions, decision makingjudgement, emotion,
or behaviour. An intoxicated person is more likely to suffer from burns, suffocation, scizui\
poisoning, overdose, sudden death etc. They may also be involved in accidents, violent,
unsafe sex and rape. Intoxication is highly dependent on the type and
dose of substance and is influenced by an individual’s level of
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tolerance and many other factors. It is not always clear when
street children are intoxicated as intoxication with different
substances has different signs and symptoms. In general, an
intoxicated person will have the following common signs;
they may be exceptionally sleepy, have trouble in thinking
and speaking and talking to them may be difficult. Their
eyes may be dilated, they may giggle or laugh
inappropriately (sometimes in response to hallucinations)
their mood may switch quickly between highs and lows and
they may become aggressive.
Even when it appears that a street child is intoxicated, it
should be remembered that some of the signs and
symptoms may be caused by other physical or
psychological states, such as hunger, sickness and Intoxication is a temporary state that follow,
use of one or more substances
emotional difficultics.
\\ (>i kin!'.
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n Harmful use.
Harmful use is a pattern of substance use that
I//
results in damage to physical or mental health.
Most physical harms experienced by street
children following the use of substances occur as
a result of intoxication, hence health damage
can also occur with experimental and
occasional use. Other harms result from the
way in which the substance is used. Injecting
drugs is particularly dangerous because it can
lead to an overdose or it may increase the risk of hepatitis, 111V and other infections from
contaminated needles and syringes. Smoking substances can result in disorders of the
respiratory system and burns. Some substances such as leaded petrol, benzene and coca
paste are particularly toxic and can cause health damage in even small amounts. As most
street children have not been using substances for long enough it is unusual to see them with
disorders such as alcoholic liver disease or smoking related lung cancer or heart disease
which occur late in life.
Dependent use.
(
This is a pattern of substance use in which the user
has a strong desire to take the substance and can-------not control its use. Thus substance use gains
priority over other activities for the user.
Long-term use increases tolerance as their
body adjusts to the substance so that the
same amount of substance no longer produces the
effects. They may also experience physical withdrawal
reactions if he or she goes too long without the substance.
Users who are dependent may continue to use substances
despite very serious consequences, 'fhey may spend more and
more of their day involved with substances.
Speild Ino,.e oflhe day
'Xp
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Withdrawal
When a person stops taking a particular substance that he or she has been using regularly, he/
she may experience adverse effects known as withdrawal symptoms. Unless young people have
been using large amounts of the substance for a long time, they rarely need to be weaned off a
substance in a medical setting. They can be assessed and managed in other safe places with
their cooperation. The most dangerous withdrawals arc from alcohol and hypnosedatives,
which may trigger convulsions and delirium. In these situations medically assisted
detoxification may be advisable. Common withdrawal symptoms of various substances are
shown in the (able.
Module
11 ikIvi sl:indino Sohsf nmc I
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Substances
Withdrawal symptoms
Alcohol
Anxiety, tremors, vomiting, sweating, convulsion, delirium (confusion &
hallucinations)
Nicotine
Opioids
Nervousness, sleep difficulty, abdominal pain, poor concentration, muscle
spasms, headaches, cough, changes in appetite
Anxiety, sweating, muscle cramps, runny nose, vomiting, diarrhoea, sleep
'
difficulty
1
Hallucinogens
No significant withdrawal symptoms
Cannabis
No or mild withdrawal symptoms
Hypnosedatives
Anxiety, irritability, inability to sleep, muscle cramps, convulsions, delirium
Stimulants
Caffeine: headaches, tiredness, aches and pains, anxiety
Amphetamines:fatigue, hunger, irritability, depression, suicidal feelings,
sleeplessness
Cocaine: fear, depression, nausea, vomiting, tremors, muscle pain, tiredness
Inhalants
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No significant withdrawal symptom
Withdrawal symptoms may include abdominal
pains or even convulsions.
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3.2 Consequences for the individual street child.
I
Using a psychoactive substance can have many different consequences. Some of the consequences
are insignificant and some arc extremely serious. Psychoactive substances have effects on the body
of the user as well as consequences on the life of the user and the whole community.
Physical
Psychological
Accidents
\
Convulsions and coma
Infections include HIV
(especially injecting drug use)
Malnutrition
Damage to body parts eg. liver, lungs,
.
nerves etc.
Cancer
Death
/ Restriction of interests and lifestyle \
Depression
Memory and concentration problems
Delirium (confusion and hallucinations)
Psychosis (fixed false ideas;
hallucinations; grossly abnormal
\
behaviour)
/
/
t
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t
Social
/
Rejection by peers, family, employers
Exploitation and violence (including murder) by drug syndicate
Inability to work and loss of income
Legal problems due to:
• Behaviour under the influence of substances
\
* Crimes committed to obtain substances
/
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Moduli
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3.3 Consequences for the family and Community.
I
Everyone, including street children, occasionally has conflicts with family members, friends JI
strangers, and lovers. Like other young people they also want the excitement of taking a risk fromjl
time to time. Substance use can sometimes make these experiences unpleasant or even dangerous.
Here are some consequences for the family and community.
©
Important responsibilities may be forgotten, and disagreements can become emotionally or
physically destructive.
Subslancc users with liltlc income arc constantly I’accd with the problem of finding money Io
purchase substances. Some of them may steal or use violence to get the money and others
might join illegal businesses or the sex industry to earn enough money.
Activities such as building a fire can become dangerous if the children involved arc under (Ik
influence of substances because of the lack of safety already present in the situations wheix
they live.
The demand for illegal substances has produced wealthy and powerful organizations iliaJ
manufacture and distribute substances in some parts of the world.
Example
Brazil.
Drug syndicates in Brazil train some street boys for dangerous, but profitable careers in
trafficking. A boy enters the organization as an olheiro whose job it is to inform others when
police or rival drug groups are in the area. Olheiros might signal the presence of police by
flying kites. The next stage of training is to transport drugs as an aviaoziniio. Later, a boy
may be promoted to an indolador, who packs the drugs, and then to a misturador who
mixes them with other substances to increase the quantity. Some boys will eventually reach
the rank of soldado, a soldier who sells drugs. While a street boy is in training in a drug
syndicate, he earns a decent income, protection from other criminals and the police, as well
as the respect of residents in certain slum communities. The syndicate might also offer him
luxuries such as television sets. Just as important, a child in training with a drug syndicate
can usually avoid being removed from his home or the streets by the government welfare
system. To many street children, being a soldado in a drug syndicate is better than being an
abandoned child, a transgressor, or a delinquent in the welfare system. A street child's
hopes for success through a drug syndicate may end quickly and violently. I Ic may be killed
by rival organizations or by the police at any time. Once he reaches the age of IS, when he
will no longer receive special treatment by the legal system, he may be killed by his own
syndicate, ‘queima de arquivo’, to protect the secrecy of their operations.
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Learning Activity
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1. Sharing experiences.
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• In small groups, discuss your experiences on substance use among street children. Document
these experiences.
r
• What consequences have substance use among street children had on the community?
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2. Raphael.
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Raphael is a 16-year-old street boy. He likes some of the street educators who work in his
neighbourhood and he occasionally goes to a centre where he participates in activities such as
games, drama, music and literacy classes. When he was about 11, Raphael began smoking
tobacco and, by the age of 14, he started sniffing solvents. A year later he was smoking can
nabis. Most of his friends use these substances as well as others that they inject. The substances
are usually very easy to obtain. Raphael’s friends have recently persuaded him to try
amphetamine tablets. I le likes the rush he experiences when he uses amphetamines. I Io says that
I amphetamine takes his mind off his troubles. He believes that amphetamines also make him
more adventurous in his sex work. Consequently, he has begun to use it more often and has
started to think of injecting.
Lately, Raphael’s life has become more difficult because he gets involved in fights with other
street children. Having noticed these problems, you have decided to keep him al the centre
longer to reduce his access to substances. Despite all these good intentions, Raphael is irritable,
anxious and appears not to control his movements especially of his hands.
a. What is Raphael’s pattern of use?
b. What arc the current problems that Raphael is experiencing?
c. What other factors are related to his substance use?
d. What are the immediate risks of his substance use?
e. What could be the long-term effects?
3. Steven and Josie
I
Steven and Josie are both 16 years old. They live together in a shelter for homeless teenagers in
the inner city. Steven ran away from home after a violent fight with his father. Josie left home !
because his cousin’s friend had sexually assaulted him. Both are angry and cover their inner pain
by trying to act ‘tough’. The two of them have stolen goods from shops, assaulted other people,
robbed houses and stolen cars.
They use cannabis, inhaling it from a waler pipe called a bong. They also drink a lol of alcohol.
Six months ago, Steven started injecting heroin and amphetamines. I le uses heroin nearly every
day now and he experiences withdrawal symptoms if he docs not use it for a couple of days in
a row. He feels physically uncomfortable and is irritable. I'rom time to time, Josie injects
substances with Steven’s equipment. He prefers pills like benzodiazepine, which he gets from
Module 3
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doctors or buys on the streets. Josie is frequently involved in commercial sex. Steven too is
involved in this, but to a lesser extent. Both of them are not interested in getting any form of
education or vocational training. They claim that they do not want to live beyond the age of 21.
• What is Steven and Josie’s pattern of use?
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• What are the current problems that Steven and Josie are experiencing?
• What other factors are related to their substance use?
• What are their immediate risks?
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• What could be the long-term effects?
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Lesson 4 - Applying the Modified Social
Stress Model in substance use
The Modified Social Stress Model is a framework which has been used by the WHO street children
project to understand the vulnerability to risk behaviour and situations associated with substance use.
This model could also be applied to sexual behaviour. The model has six major components; stress,
normalization of behaviour and situations, effect of behaviour and situations, skills, attachments, and
resources. Stress, normalization of behaviour and situations and effect of behaviour and situations
(lhe experience of substance use) are viewed as factors that may increase vulnerability. Skills,
resources and attachments are seen as factors that may reduce vulnerability to risky behaviour and
situations. However, each of these factors has aspects which can increase vulnerability (risk factors)
or decrease it (protective factors).
fhe model serves as a guide to factors which may contribute to street children engaging in various
risk behaviours. The basis of the model is this: if many risk factors arc present in a person's li fe, that
person is more likely to begin, intensify, and continue the use of substances, and experience related
problems. Conversely, the more protective factors that are present, the less likely the person is to
become involved with substances.
Vulnerability can be understood better if both risk and protective factors are considered at the same
time. Besides providing a conceptual understanding, the framework is useful for planning
interventions to prevent or treat problems such as those related to substance use, sexual and
reproductive health including HIV/AIDS/STDs, at both the individual (street child) and the
community level.
Each component presented in (he model can have positive and negative aspects that function as risk
or protective factors. I’he following pages apply the model to substance use and illustrate the
components as they might appear in a street child's world. The model will later be applied to sexual
and reproductive health.
d
d
d
d
...
------
Stress
. --------------- !______ ,_________________ _
Effects of behaviour and situations |
Normalization of behaviour and situations
Attachments
SkiihT
| Resources
Risk Behaviour
Risk factors increase
Protective factors increased
27
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4.1 Stress.
Stress is the way a person feels (e.g., anxious, tense, burdened) in response to real or perceived J
stressors. A stressor may be observable (e.g., violence, poor living conditions, a physical disability), J
or it may be less visible to others (e.g., emotional abuse, trauma). The more stress a child is under,
the more likely he or she is to use substances. Street children often have extremely stressful lives. I
To understand just how stressful their lives can be, consider the five types of stress
J
(adaptated from Rhodes and Jason) that are described below.
Major Life Events.
Dramatic events that have a profound effect on the survivors. They
include death of parents, abandonment, serious accidents, natural
disasters, demolition of home by authorities, war, physical and sexual
assaults, and suicide attempts. Street children may use substances
after the event to lessen the pain of the event and to help them
adjust to their new situation, which is inevitably worse than before.
Dramatic events have a
profound cjfect on (he survivors
Enduring Life Strains.
'Phe lives of street chiklren are usually filled with long-term problems that are difficult to
solve: poverty, denial of human rights, psychological difficulties, illnesses, and lack of
educational and recreational opportunities. Rejection or a sense of rejection by family
members, friends, school, health or other services, and society in general can also make the
street child feel a sense of loss similar to that experienced when someone close to one dies.
Using substances may provide excitement, or help in imagining a better future and offer
relief from physical pain. Substances are sometimes used to decrease
guilt feelings and pain related to providing sex for money.
School
C
Social isolalion. loneliness
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Everyday problems.
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Most of a street child’s time is
spent working on survival
issues; finding food, clothes and
shelter, and avoiding violence
and the police. They often have
ongoing conflicts with other
street children, merchants and
community members or
authorities. I his daily struggle
is tiring and leaves little time
for other things. Substance use
offers a quick and easy escape
from day-to-day problems.
Conflicts with other sli ce/ children, inert hunts and
coininunity members arc common.
n Life transitions.
(
Transitions in life, such as moving
neighbourhoods or cities, changing
peer groups, or beginning a romantic
relationship, are always stressful
because they require people to
behave in new ways. People
may use substances during
the transition to reduce
their anxiety. If a street
child's new friends use
substances, he or she may
imitate their behaviour in order to
be more easily accepted.
Life transitions may require street children to behave in new ways.
Although stressful, some life transitions may result in a positive situation foi stiect childicn.
A familv
family move mav
may brine
bring the street child who stays with his or her family at night into contact
with different people who may have a positive influence.
(
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® Adolescent developmental changes.
All young people go through physical, psychological, and social changes during their 9
adolescent years. These changes arc particularly difficult for street children who are becoming 9
adolescents because they have no one to explain to them about these changes. They may not
have had access to adequate adult role models and they may not get the opportunity to 1
gradually assume more adult roles and responsibilities or negotiate such roles with parents and J
other adults. For example, street children may have to find a new source of income after
puberty and may be enticed into commercial sexual activities. It can be confusing and de
pressing for street adolescents to cope with the immaturity of
their bodies, especially while they are dealing with adult
responsibilities. Street children
want to be accepted by their
peers even more than the
typical adolescent.
Joining in when their
companions use sub
stances or engage in
other activities that
can harm health are
ways to be accepted
They want Io he accepted hy their peers. Ji
more easily.
Sometimes stressful events and situations may be associated with positive outcomes for street w
children. The change brought about by the event may ease their situation in some cases, c.g. <
the marriage of a widowed parent may be stressful, but it may improve the family situation.
The rebuilding of a community after a natural disaster may bring new educational resources or
work opportunities for street children and their families. A family move may bring the shed
child into contact with people who may have a positive inlluencc. Growth and strength that
come with adolescence are highly valued by many boys and girls. They may believe that they
will not be abused as much, that the smallest members of their community will admire them,
and that they may get better jobs. Stressors may lead to a positive outcome in yet another way.
If the child negotiates a difficult situation successfully, it may enhance his or her self-esteem.
Careful assessment of the actual positive or negative results of key life events on
individual street children, their families and their communities is necessary to
understand the full impact of stressful events and situations at risk of substance use.
Although many street children seem to possess remarkable abilities to cope with
difficult circumstances, some street children may be particularly vulnerable.
Understanding what different street children regard as most stressful for them, and
how they are dealing with these stresses, is vital for developing specific ways to help
them.
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4.2 Normalization of behaviour and situations.
I
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According to the Modified Social Stress Model, a person is more likely to become involved with
substances if using substances is considered normal in the person’s environment. Many street
children live in places where other street children, the adults in the neighbourhood, and even the
entire society accept the use of some substances. This makes it easy for them to use substances as
well. Factors that encourage a group or an entire society to accept the use of a particular substance include:
Legality and law enforcement.
I fa subslancc is legal, il is much more likely to be accepted or normalized in general society,
fhe use of illegal substances that are tolerated by the authorities could be acceptable to many
people, including street children.
Availability.
The easier it is to get a substance, the more likely it will be normalized, as with the use of
caffeine, alcohol, and tobacco which have become normalized in many countries across the
globe. On the other hand, restrictions imposed on the manufacture and sale of psychoactive
medicines limit their availability and make it less likely that their use will be normalized. The
same principle holds for illegal substances. If they arc easy to obtain, they arc more likely to
be normalized. 'The use of cannabis, which is widely available in some places, is acceptable to
many members of the community even though it is illegal. Coca paste is used by many youths
in the Amazon basin where it is produced. Volatile solvents, including petrol and glue, arc
readily available in almost all areas of the world.
Ifsubstances are easier to obtain they
are more likely Io be normalized.
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Price.
The more affordable a substance is, the more likely it is to become normalized within a group
of consumers. Substances that arc normalized among some street children arc the ones that arc
the least expensive (and most available). Glue, solvents, and petrol are cheap in most areas.
Crack cocaine has become one of the favourite substances of street youth in the United States,
partly because of its low price.
Advertising, sponsorship and promotion.
When substances are promoted (through advertisement or
sponsorship of activities) in a community, residents are
presented with the idea that using substances is normal
and even desirable. Many promotional campaigns for
tobacco and alcohol are designed specifically to
encourage their use by young people. These include
advertisements and sponsorship to activities at sporting
events with celebrity athletes, youth festivals, and at
‘rock’ concerts. People involved in the drug trade may
promote illegal substances in some communities.
Street children are easily influenced by advertising,
promotion and sponsorships. Without many
heroes and successful role models in their own
confined world, they often fantasize about the lives
of celebrities and look to them for inspiration and
direction.
1
r
Many promotional
campaigns for tobacco and
alcohol are designed
specifically to encourage
their use by young people.
Media presentation.
A frequent and positive portrayal of substance use
on television, in films, books, comics, and street
theatres encourage normalization. Characters
are shown smoking cigarettes, drinking
alcohol, or taking substances in an
atmosphere of excitement, danger, or
sex. Equally problematic is the
depiction of substance use as a normal,
everyday event. Street children, many
of whom were raised in stressful or
atypical homes, may be easily
influenced by what they see in the
media because they many not have
other sources of ideas and
information.
Positive media portrayal eacourayes normalization.
1
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Community acceptance.
(
People tend to accept the use of a substance when the production and sale of the substance is
an important source of income for the community. Some street children live in areas where
substance production and trade arc the major source of income for most of the residents.
I
The leaders of alcohol, tobacco and other drug companies may be important members of the
community. In certain slum areas, this is true of even illegal drug trailickers. They are
admired by some of the residents because of the money they earn, and because they
sometimes provide financial and other senices to the residents that are not provided by the
government or other agencies.
Cultural role.
Substances that have a place in the traditional culture of a society arc usually normalized. The
use of at least one substance has a cultural purpose in almost every society in the world. In
religious activities, some Christians and Jews drink alcohol and some indigenous communities
use hallucinogens. In many cultures, alcohol is used to celebrate special occasions such as New
Year’s Day and weddings. In parts of Asia, opium may be smoked during social gatherings and
for relaxation. Cannabis is used for cooking and socializing in parts of Africa and Asia.
I
Even when governments make a traditional substance illegal, some ordinary people may
choose to continue using it because it is an important part of their traditional lives. Street
children, like everyone else in the society, are influenced by the role of substances in their
culture.
When deciding whether it is normal to use substances, a person looks at the behaviour of people who
are similar to him or her. These people, called a peer group, might I ind the use ol certain substances
acceptable in certain situations, even though it would not be acceptable to the general society, l ot
example, it is considered normal in some groups of young people to openly smoke marijuana at
musical concerts, although this would not be acceptable to other groups of young people or most of
the adult population. The peer group for a street child is usually other street children of similar age
who are involved in the same type of work as he or she is. Each peer group has its own unwritten
rules about the use of substances. Working children in Mumbai, for example, accept the use ol
solvents, but they don’t approve of sleeping tablets because the effects last too long and they feel too
tired to work.
33
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4.3 Effect of behaviour and situations: the experience of substance use.
I
Many street children use substances because the substance adds something to their life such as
entertainment, or it temporarily solves a problem. Street children use substances because substances
lessen hunger, add excitement, decrease physical and emotional pain, induce sleep, may increase
energy levels to work, improve alertness, provide a form of recreation, provide a feeling of belonging
to the peer group or may even give the courage to commit crimes. If a substance produces a positive
or desired experience for a street child, he or she might use it more frequently.
The effect that a substance has differs from person to person, and from occasion to occasion. The
exact effect that a particular substance has on a particular individual depends on the user, the
substance and the setting.
<ȣ-
’J
The User
The Substance
The person’s physical condition and \
state of mental health
>
• The person’s expectations about the effect of
the substance
/
x.
The person’s past experiences with
substances
'
® The type of substance
• The strength and purity of the substance
• The route of intake
®
/
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THE EXPERIENCE
The Setting
9 The atmosphere of the occasion
• The physical environment
• The expectations of the group
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Some street children claim that even if they don’t like the effect of a particular substance, they may
still continue to use it because the experience they have is better than the boredom of their daily lives
and thus it becomes a desirable experience. Hallucinogens are an example of such a situation.
Hallucinations have been described as having a ‘magical’ feeling, even though some of the
experiences can be very frightening. Understanding what the street children like about the effects is
important in planning interventions. Negative experiences of taking substances such as a bad
‘hangover’, frightening hallucinations or panic reactions can decrease the likelihood of use.
I xainplc
Andre in Mexico City talks about his experience.
I
“My best hallucination was to see little green flowers, elephants and the Pink Panther. The
last time they put me into the Centre (Juvenile Detention Centre), we were sniffing glue with
a few friends and a guy invited me to sniff toluene and so 1 did. Suddenly, 1 couldn’t see my
friends anymore, I couldn’t see anyone. I saw I was in this bloody dark room, as though there
was no one. It was really dark, and then I saw some little lights which got closer. Then the
lights got bigger and just as I was about to get close to them, I fell into a big hole. When I
fell down, there was a bunch of skeletons and they got up and told me 1 was going to die,
that I didn’t have much time left, and that I wasn’t going to live beyond that night. I wanted
to scream and talk to my friends, but the words stuck in my throat. I wanted to shout, but 1
couldn’t. I didn’t know if anyone could hear me. The thing is, that day I thought 1 was going
to feel bad forever, and I wanted the trip to stop. That was a pretty wild experience, don’t
you think? “
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I
4.4 Attachments.
Attachments are personal connections to people, animals, objects and institutions. Having al least
one person with whom someone has a close bond and feeling of acceptance has been found to be
vital to developing a sense of positive self-esteem. A desire for close relationships can make a street
child vulnerable to close relationships with people who can have a negative influence. A street child
is more likely to develop strong attachments to other people if:
I
• He or she spends a lot of time with them
«» He or she performs well in that group in any activity
• I le or she is consistently rewarded by the group
■■
Street children are less likely to begin using substances and more likely to stop using them if their
strongest attachments arc with people and things that arc not connected with substance use.
Unfortunately, the situation of many street children makes it difficult for them to keep in contact with
their families, to succeed at school or work, or to surround themselves with friends who do not use
substances.
Negative attachments are connections to people or institutions that arc associated with substance use.
abuse or exploitation such as drug syndicates or peers who use substances. Negative attachments
make substance use more likely.
Positive attachements!
Other street children.
Family.
religion
Animals and pets.
JT
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4.5 Skills.
(
Skills are competencies. Competencies
include physical and performance
capabilities such as juggling, vending, craft,
and self-defence, and psycho-social skills
(e.g self-awareness, assertiveness,
problem solving etc.) needed to deal
effectively with the demands of
everyday life. These skills arc often
called psychosocial life skills (refer to
Modules 6 and 7). All young people
Selfassurance.
need to develop physical, psychological,
social, moral, and vocational
competencies as a part of their healthy
development.
Seeking support from others.
57
(
Coping strategics arc the cognitive,
behavioural and social abilities that help a
person manage stress. Competencies
become coping strategies when
they are used to manage stressful
situations, e.g. seeking support from
others or retreating in the face of
danger. Competencies also help young
people prevent health problems and
cope with them if they occur. If street
Know ing when to retreat.
Asertiveness.
children have more skills it is less likely
that they will need substances to meet challenges or to cope with problems. 11 they do
use substances, they will have a greater ability to control the amount of use and avoid problems
related to substance use.
Children may be exploited because of their age and general vulnerability during the process of skill
development. This may include being paid less or being forced to work longer hours compared to
other older workers. Under such circumstances, children may use substances to stay awake oi to keep
up energy levels and then use different substances to sleep or relax.
The skills developed to survive on the streets, such as the ability to steal or lie to people in authority,
can have a negative side in increasing illegal activities such as drug trafficking. This can result in
increased use of substances in the community and by the individual. Lying prevents the development
of trusting relationships.
MihIiiIi
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4.6 Resources.
Resources are used to meet physical
and emotional needs. Resources can be
inside a person, such as a willingness to
work hard, or in the environment, e.g.
schools, money, and people who care
about the person. Examples of
resources are:
hitciiinl resources.
hilnriiuiiion
.i
h»
Intelligence.
Capacity to work.
Education.
Vocational skills.
Religious faith.
Optimism.
Sense of humour.
$ External resources.
Information.
Family.
Other street children.
Street educators.
Positive role models.
Community organizations.
Educational and vocational
training services.
Health services.
Employers.
Recreational facilities.
i
I
Recreational facilities.
s
Other street children.
I
il
T|.
i
A sense of humour.
Street educators.
i
Even though street children usually have many internal resources, they often lack external ones.
Without external resources, it is often difficult for street children to learn new skills that would
help improve their lives. They may fail to develop healthy ideas and practices about substance use
if they do not have the benefit of resources such as street education and informational campaigns.
They also have fewer alternatives to substance use for relieving stress when resources such as
recreational and vocational facilities are lacking. Resources need to be accessible and appropriate
to street children.
Under the Modified Social Stress Model the likelihood that a particular street child will use
substances will change from time to time so that during more stressful periods the child is
more likely to use substances; even during periods when changes occur, it is important to look
at all six components of the model at the same time to understand what a person might do.
-
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I
\\ <>l I ill- \■. ilh - I-
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t
Learning Activity
1. Your Life Graph.
Now that you know the components of the Modified Social Stress Model, use them to under
stand how everyone, street children, and you yourself, go through stressful periods when strong
attachments, competencies, coping strategics, and resources are needed to improve the situation.
Start with your own experience of stress and coping. Use a pencil for this exercise so that you
can make changes as you work.
This exercise asks you to think about situations in your own life. 'The information about yourself
is private. You may be asked to talk about what you have learned from this exercise, but you do
not have to share your personal history in the group discussion. However, some street educators
may find it helpful to discuss personal issues that this exercise may expose with someone they trust.
Sample Life Graph.
5-i
(liappicsl)
4K
3217(iinhappicsl)
Liw
0
10
T
20
i
40
30
r
50
T
60
T
70
Age
1. Begin by deciding when the happiest time in your life was. Place a mark at level five on the
vertical scale above your age at that time.
2. Then think of one or two other good moments in your life and mark them above the
corresponding age at a height below five.
3. Now, do the same with your emotional low points. Begin with the time when you were most
unhappy and mark that at level 1. Continue with one or two other low points.
4. Circle the low points that you have placed on the graph.
These items represent the stresses that you have experienced in your lite.
Modi.I,
'
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5. Now try to recall the persons, places, situations, or events that made that period of time
particularly difficult and list them on the lines below.
I
1
]
6. Draw lines on the graph between each low point and the high point that follows it. These
items are examples of your positive attachments, skills, and resources.
7. Then try to recall the people, behaviours, organizations or events that helped you to endure i
the bad times and raised you to a high point. Write them down on the lines below.
.
_________
-
-
-
u?
-J I
J
8. Next, compare the two lists. Do any items appear on both lists? It is possible that positive at
tachments such as family members, friends, school, and work can sometimes be stressors.
K)
V'?-'•T*'ST7
1
WOi kin<4 W ith Slricl < liihlicn
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2. You and substance use.
You will be able to understand other people’s use of substances better if you first examine your
own behaviour. Try to be honest and answer the following questions completely. You do not have
to share information about your personal history in the group discussions. This is a confidential
exercise to help you to understand your own behaviour better.
1
1. If you use substances now or have in the past, list the factors which influenced your decision
to start, increase or restart substance use according to the Modified Social Stress Model.
Stress
Normalization
Substance Experience
Attachments
Skills
Resources
2. If you do not use substances or you have stopped or decreased its use, describe the factors
that influenced your decisions.
Stress
Normalization
Substance Experience
Attachments
Skills
Resources
11
K
!
I udci sf iiiidiii” Subsfunct I
Module '
\ inonj’ St reel ( hildi cd
i
3. Normalization.
I
For each substance that is used by street children in your area, estimate how normalized the
use of the substance is by answering the following questions.
Substance
Is it legal?
To what exlent are (he laws about its distribution and use enforced?
I
Issues:
In the community:
Availability
Price
Economic and Political
Role of the substance
or the manufacturer
Cultural Acceptance
•
Advertising and Sponsorship.
How is the substance advertised?
Who arc the intended targets of the advertisements?
12
For street children & their families:
. Hi
----------------- ■■
W oi'kino W ith Sti rrf < liihlrcn
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f
Are street children a part of the targeted groups or would they be attracted to the images used?
Promotion.
How do the manufacturers and distributors promote the substance?
Media Presentation.
How is the substance generally portrayed in the media?
What medium has the greatest impact on street children in your area? (Consider television,
films, radio, musical recordings, comic books, other books, etc.)
How is the substance portrayed in this particular medium?
Peer Group.
How frequently is the substance used by street children in your area?
1 low frequently do other people in the community who are close to street children use the substance?
I*
t
••kJ
Moduli' 3
I ndi rstiindiiio SobstuiH c I
Xiiioiio Street ( hildi co
1
Overall Normalization.
How normalized is the substance for the community as a whole? (tick one)
• not normalized.
• partially normalized.
• normalized.
)
How normalized is it for street children? (tick one)
• not normalized.
• partially normalized.
•
normalized.
(
i
I
44
. jssra.
Working With Sired ( I ildreii
I
4. Applying the MSSM to the use of substances by a street child.
(
i.
Raphael.
(
Review the completed case assessment of Raphael, and think about how the components of the
model apply to his life.
Sixteen years old Raphael is a member of a group of young, male sex workers. He has lived
away from home for five years. He currently lives in a single room with three other sex workers.
Raphael’s father drinks alcohol regularly. When he is drunk, he often beats his wife and children.
Raphael loves his mother and siblings and sees them when he can. They are always happy when
he visits. Raphael gives his mother whatever money he can spare. He hopes that some of the
money can be used for the education of his younger siblings.
During his time on the streets, Raphael has been beaten and raped by other street children and
some of his clients. Some of the other sex workers are good friends, but some harass him by
calling him ‘gay’ and by telling him “you have AIDS and you are going to die”. Raphael does
not know if he is infected with HIV, the virus that causes AIDS, but he is afraid to go to the
health clinic to be tested.
(
Raphael likes some of the street educators who work in his neighbourhood and he occasionally
goes to a centre where he participates in activities such as games, drama, music and literacy
classes. When he was about 11, Raphael began smoking tobacco and, by the age of 14, he started
sniffing solvents. A year later he was smoking cannabis. Most of his friends use these substances
as well as other kinds which they inject. The
substances arc usually very easy to obtain.
I
Raphael’s friends have recently
persuaded him to try amphetamine
tablets. He likes the rush he
experiences
when
he
uses
amphetamines because the effect takes
his mind off his troubles. He believes
that amphetamines also make him
more adventurous in his sex work. /
He has now begun to use more often
/
and has started to think of
/
injecting. Lately, Raphael’s life
/
has become more difficult. He
misses his mother and siblings
more and the harassment by
the other sex workers has become worse. He has been asked
by his roommates to find another place to live.
(
15
K
"T
T
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Module 3
I'ndcrskiiHliii” Subsf-.incc I
\ 111011J4 St reel ( liilili cn
Example of using the Modified Social Stress Model Model on the case of Raphael
Stress
Normalization
Substance Experience
Father unavailable, abusive
Worried about family and HIV
Harrassment and Violence
Needs new place to live
Alcohol normalized at home
Feers use substances
Substances affordable and
available for him
Enjoys feeling of intoxication
Forgets problems
Improves his work
Attachments
Skills
Resources
Mothers, brothers and sisters
SI rnril |\li|f..-il or
Other children
Able to save money
Sox woi k
Some reading and drama skills
Mother
Accniio Lo drop In criil inf.
Proven resilience for 5 years
Motivated to survive
Seriousness of Current Use: N/A
Potential for Future Use:
Nil
Low
Medium
High _
Low
Medium
High rr
j
1
Other comments and Plan for Action.
History of persistent and increasing substance use
Level of stress is high and increasing
Might not increase use if he could have more contact with his mother and could find a place to live.
Encourage him to move into the local youth shelter. Ask his permission to contact mother.
io
I
_ \\ oi kino \\ i(|| ,Sf reel ( liildren
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Review the completed case management record on Raphael on the previous page.
Determine whether you agree with the points made. If you need to change anything,
complete this form again for Raphael.
Stress
Normalization
Substance Experience
Atlnuhniunls
Skills
Resources
Seriousness of Current Use: N/A
Low
Medium
High
Potential for Future Use:
Low
Medium
High
Nil
Other comments and Plan for Action.
Lesson 4 a way of assessing and documenting information about the situation of individual
street children according to the categories presented in the Modified Social Stress Model was
introduced. Understanding the risk factors which increase the likelihood of substance use and
protective factors which can help make use less likely for individual street children is a core part
of case management process. You will practice more case management in Module 8. The case
assessment in Module 8 allows you to get even more information and this will provide you with
a stronger base for planning interventions
I
Module 3 - IIndrislaiiding Subslance I se Amon” Street ( hildien
I
J
Bibliography and further reading
Bucnctt l< (1997). The street children in Kenya. Kenya, Christian Aid.
Orlandia M A. Ed (1992). Cultural competence for evaluators: a guide for alcohol and other drug
abuse prevention practitioners working with ethnic/racial communities. Washington. U.S,
Department of Health and Human Service, Public Health Service, Alcohol, drugs, Abuse, and mental
Health Administration (OASP cultural competence series 1).
Rhodes J & Jason L (1988). Preventing Substance Abuse Among Young Children and Adolescents.
New York. Pergamon Press.
WHO (1997). Cannabis: a health perspective and research agenda. Geneva, Substance Abuse
Department, World Health Organization, 1998, WHO/MSA/PSA/97.4
WHO (1994). Lexicon ofAlcohol and Drug Terms. Geneva, World Health Organization (ISBN 92 4
154468 6).
WHO (1973). Youth and Drugs. Geneva, World Health Organization (Report of a WHO Report
Series, no. 516).
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Module 5 - Determinin’; the Needs and Pioblems ol’Street ( hildren
Contents
Page
Introduction.
Lesson 1:
Assessing the situation.
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Importance of assessing the situation,
fhe goal of the assessment.
Possible sources of information.
Importance of service providers as a source of information.
Basic steps to be followed.
Important considerations during collection of information.
Suggested areas for assessment and use of the Modified Social
Stress Model for collecting information.
1.8
Methods for collecting information.
Learning activity.
Lesson 2:
i
3
3
•I
I
6
Asking questions.
2.1
2.2
Why is asking questions important?
How should questions be asked?
2.3
Question menus.
9
Learning activity.
Lesson 3:
Methods for collecting information.
3.1
3.2
Collecting information on street children,
focus Group Discussions.
3.3
3.4
3.5
Case studies.
Observation.
31
Key Informant Interviews.
32
The narrative research method.
3.6
3.7
Surveys.
Projective methods.
3.8
Learning activity.
33
Lesson 4:
Analyzing information and preparing an Action Plan.
Analyzing information from a FGD.
4.1
4.2
The Action Plan.
Learning activity.
Bibliography and further reading.
31
34
35
36
37
U)
in
\\ orkin” Willi Sheet ( hildien
I
t
Introduction
Information on local street children needs to be collected because the characteristics and situations
of street children arc different in every country, city and neighbourhood. General books and other
written materials about children will probably not provide enough detail, as street children lend to be
excluded in population censuses or household surveys.
Assessments help in formulating workable strategies for responding to the needs and problems of
street children. For example, the kind of services needed, and how and where the services should be
offered. Assessments also help in monitoring whether services are producing the desired effect and
whether there is a need for a change in strategics. Results from the assessments should be used to
create awareness about the causes of street children’s problems and their relationship with other
issues.
(
Determining the situation of street children requires a collective effort. A variety of people could be
involved, such as government officials, religious groups, skilled professionals, service providers,
NGOs working with street children, other interested community members and street children
themselves.
This module outlines the aspeets related to information gathering and what is involved.
I
Learning objectives
After reading the information in this module and participating in the learning activities you
should be able to:
Explain the importance of assessing the situation of street children.
Explain two ways of formulating questions.
Formulate open-ended questions.
Prepare a tool lor assessing the situation of street children.
Describe the appropriate methods for collecting information about street children.
Explain how information can be analyzed.
Prepare an action plan using the information gathered.
Module 5 - Delenninino the Needs and Problems ol Street ( hildren
Lesson 1 - Assessing the situation
1.1 Importance of assessing the situation.
Assessment helps in understanding the needs and problems of street children. It also provides an idea
about their environment. Adequate assessment is essential before any intervention is attempted.
Similarly, assessments may be carried out later to monitor the progress and success of the programme.
Modification in intervention may be made on the basis of information obtained from the assessment.
Example
India.
Focus group discussions held by a project in India revealed that many street youths were
engaging in sexual practices which put them at risk of becoming infected with HIV and
other sexually transmitted diseases. The discussions helped identify a need for basic sexual
and reproductive health education and also a need to work more with the families of the
street children.
1.2 The goal of the assessment.
Two questions define the goals of an assessment. These are:
© What specific problems should the assessment address?
® What is the purpose of collecting the information?
There is a danger of collecting information that is of no use to street children if these fundamental
questions are not clarified before the assessment begins. The purpose of the initial assessment may
be the determination of problems and needs, while the purpose of ongoing assessment may be to
provide feedback on the success of the programme. The information gathered should be closely
linked to the specific issues to be addressed. In this module you will be thinking more about
information related to substance use.
I
Working W ill) Sli cel ( hildrcn
t
I
1.3 Possible sources of information.
Information can be obtained from primary and secondary sources. Street children and their families,
health care and other service providers are primary sources of information, fhc common
secondary sources of information are:
© Official documents such as surveys, policy statements, professional guidelines, registers and
court proceedings on street children.
Unofficial materials from government or medical institutions and private individuals, e.g.
television and radio programmes, evaluation reports on street children, books, newspapers and
magazine reports and copies of presentations at professional and community forums can add
to the resource materials.
Secondary sources provide the background for designing assessment procedures. Usually they
do not provide sufficient information for a complete understanding of the situation of street
children. Information should be gathered from primary sources to supplement secondary
information. Primary information also gives you qualitative data (feelings, views, beliefs and
aspirations).
1.4 Importance of service providers as a source of information..
Service providers can be an important source because they can provide information
on:
I
©
the economic, social and political conditions of the community.
©
community altitudes towards street children, substance use, sexual
and reproductive health.
©
services available in the area, particularly those accessible to street
children, potential barriers to their use by street children, and how
to overcome such barriers.
©
what interventions have worked, or failed (this information is critical for
designing interventions).
Secoitdai v sources <>! inl<>rin<iti<>n hsiui/Iv d<>
mil firovidr <dl llic iulorimilum rciiuu ed.
3
Module 5 - Delerininiiio lhe Needs and Problems of Street ( hildren
1.5 Basic steps to be followed.
After deciding on the goals of the assessment, the following steps should he followed:
1.
2.
3.
4.
5.
Make a plan regarding the method for obtaining information (when, where, how and by whom).
Collect the information.
Organize the information.
Analyze (he information.
6.
Use the information.
I
Make conclusions.
1.6 Important considerations during collection of information.
The following issues should be kept in mind during the assessment of substance use and sexual and
reproductive health problems among street children.
® Informed consent.
lhe street child should agree to participate. To get valid consent, inform the child about the
goals and method of'the assessment, what they would gain or lose if they participate and also
that they are free to refuse to
participate.
© Confidentiality.
30
All assessment information
should be kept confidential,
unless you have the street
child’s consent to give
I!
information to others. Talk
to the street child away
from peers, family and
others. Their presence may
compromise confidentiality.
Similarly, the confidentiality of’the informants is
extremely important. In some countries,
children and other informants have been
murdered for providing information.
Rapport.
Talk la the Mrcci child aw<i\
from /)ccr\ and famdics
lhe process of assessment is not just lhe collection of in Ion nation as il can be an oppoi luiiilx
to engage the street child in a respectful and trusting relationship, l he assessment could
provide an opportunity lor street children to ask questions and get information if they choose
Io do so.
4
1
Workin}’ Willi Slrecl ( Inhlien
t
o Burden.
Street children might have been assessed many times by health, welfare, educational, legal and
other agencies. Try not to duplicate assessments that have already been done. Street children
tend to have a short attention span, so avoid asking too many questions (it may be useful to
spread the assessment over more than one session to make the process less demanding).
I
® Priorities.
During the assessment, you may come across conditions and/or situations which require urgent
attention, such as injuries or threat of violence. Attend to these priority issues before dealing
with substance use or sexual and reproductive health.
1.7 Suggested areas for assessment and use of the Modified Social Stress Model
for collecting information
Information should be obtained in the following areas:
•
•
•
•
•
•
•
•
•
Background: age, gender, religion, cultural background.
Substance use.
Sexual and reproductive health.
Physical health and injuries.
Mental health and psychological trauma.
Family and social.
School and vocation.
Unlawful behaviour.
Recreational and cultural activities.
The Modified Social Stress Mode! can help you decide on the questions that can be asked regarding
the problems and the potential of street children. Sample questions have been included in Lesson 2.
1.8 Methods for collecting information.
To obtain quality information about street children, methods suitable for small groups of people should
be used. The choice of the method will depend on the type of information needed. These methods are:
©
e
©
©
0
Focus group discussions.
Case studies.
Observation.
Key Informant interviews.(in the street context, the term "informant” often means "police
informant".Therefore replace the term informant with a more acceptable term when
introducing the concept during assessment).
Narrative research method.
Surveys.
Projective methods.
The details of each of these methods are described in Lesson 3 of this module.
5
1
Module 5 - Determining (he Needs and Problems ol Street ( hildren
I
Learning Activity
1. Purpose of the assessment of street children’s situation.
•
I
Write about the specific problem that you want to assess or have assessed earlier.
i
Outline the intended use of the information collected or to be collected.
2. Identifying secondary sources of information about street children.
•
As a group or individually, identify possible sources of existing information about street
children and make a list of these sources.
1
Visit at least 3 places identified above. If you are working in a group, you could divide the
group so that you each visit a number of these places. At the location:
•
•
®
Identify the type of information that exists.
Collect copies of documents (if permitted).
Analyze the information and make a summary of your findings (include the
information on demographic data, services and resources).
f
6
1
Working With Street ( liiklren
t
I
Lesson 2 - Asking questions
2.1 Why is asking questions important?
speak spontaneously about their lives, especially to a stranger. '1 hey
Many street children will not :,
have learned to be careful about who they give information to and1 arc suspicious of adults who ask
too many questions. Think carefully about what questions you need
i._— to ask and how to ask them. Ask
questions in a way that will encourage them to speak freely.
2.2 How should questions be asked?
Approach the child in a manner that will make him/ her feel comfortable Here are some simple
phrases and questions that you can use to start a conversation with the chdd:
© Getting to know each other.
(
(
Say who you are and ask the child to tell you his/her name. Address the child by name as it
Say who you
makes the child feel that you respect him or her. If the child does not respond, tel the chdd
where you work and when he or she can come to speak to you. Don t ask questions tha mig
make the child feel threatened or suspicious. Keep the questions snnplc and general. Show that
you are genuinely interested in the child.
© Asking questions about a painful subject.
When questioning a street child about something that may be painful for them to think about,
Znd some time with the child, starting with general questions, and then ask questions that are
gradually more specific. Do not assume that you know how the child feels about any even .
S^Zl reactions occur in specific situations of a person’s life Two PW e JW hi-
completely different emotional reactions to the same event, e.g. death of a father can lea
deep sorrow but the death of an abusive, violent father can also lead to a lee hug ol chef. Ik
same person might also feel a mixture of conflicting emotions about a single event as in li e
ZSX, the death of an abusive father can lead to a feeling of relief, but the chdd might
also feel guilty about feeling relieved at his lather s death.
Module 5 - Dclcrinining the Needs and Problems of Street Children
© Types of questions.
There are two types of questions: closed and open-ended.
1. Yes and No questions (closed questions). These types of questions are formulated to give
a simple yes or no answer.
Example
“Do you like living on the streets?”
“Do you go to the market to buy food?”
To a child or any individual being asked questions, a yes/no question sounds like he or she is expected
to give a one-word answer and then wait for the questioner to speak again. These questions can stop
a conversation as they discourage active participation, it is best to limit these types of questions.
2. Open ended questions: Open-ended questions encourage further conversation and more
information can be gathered about the street child, fhc process of asking such questions should be
guided by the topic being explored.
Example
“Where do you buy food?”
“I low do you manage to get food on a daily basis?”
Some younger children will not be able to answer open-ended questions. If they do not
answer or say something irrelevant in response to the question, ask them a more specific
question. If they still do not answer, stop asking about that topic and just say something such
as “You can tell me about it later if you want to.”
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2.3 Question Menus.
The WHO Street Children Project on substance use has developed a long list of questions designed
to provide information about the six components included in the Modified Social Stress Model. A
key question has been written about each of the six components ol the model. In addition, many
follow up questions or ‘probes’ have been included to obtain more detail about specific issues.
These questions have been written to give ideas as to the type of questions that may be asked and the issues
that may be raised in the inquiry. You can select specific questions that are relevant for your needs. These
questions can also be used as examples for creating your own list ol questions by rephrasing them in a
language which is more appropriate for the street children you are working with. Add questions il needed.
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Consider the age and cultural background of the children before choosing any questions. When
choosing questions for adults, consider their professional, cultural, and religious background. Some
of the questions, especially those in the general health and risk behaviours sections, may not be
appropriate for your particular setting because of their sensitive nature (such as questions on sex and
drug use). Some questions which can be asked directly in a private interview may need to be
rephrased if they are put to a group. For example, the question “Have you ever been raped? could
be rephrased “Have street children that you know ever been raped?”
Module 5 - Detcriniiiiiig the Needs and Problems ol Street ( hildren
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Menu A : Street children.
The first menu (Street Children Question Menu) is for questions you might want to ask street
children directly in a focus group, an interview, or a survey.
1. Demographic information.
These questions provide information on the background of street children:
• Gender of the participants.
• I low old arc you? Or what year were you born?
• Where were you born?
• Can you read and write? How much schooling did you do?
• Where do you live?
• With whom do you live?
•
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Where arc your parents? Who raised you?
Where did your parents come from?
Do you practice any religion? How important is it to you?
Do you work? What type of work do you do?
2. Stresses.
a) Major Life Events.
Key Question:
1 las anything happened to you in your life that has been very difficult?
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Probes, if needed:
Have you ever been so sick or injured that you needed to go to the hospital?
1 las any one close to you died?
1 lave you ever been in a situation where you feared losing your life or being severely harmed?
1 lave you ever experienced a natural disaster, such as an earthquake, flood or fire?
Arc you a refugee?
b) Everyday stresses.
Key question:
What don’t you like about living on the streets? What don’t you like about living with your
family?
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Probes, if needed What do you like about living on the streets? What do you like about living with your family?
What do you try to avoid each day? (Problems, street children, activities)
Where do you usually sleep? Where do you sleep al other times?
Where do you usually get your food? What do you usually eat? Do you ever go hungry? If you
cannot get food, what do you do?
Where do you get your clothes? Are they warm/comfortable enough? What about when it rains
heavily? Do you ever get cold? Where and how do you clean your clothes?
Where do you go to wash or clean yourself? 1 low often?
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© Where do you get your money? Do you ever provide sex in exchange for affection, food,
clothing, shelter, drugs or money?
• Do you often get hassled? Who hassles you? Why do they hassle you? What do they do?
c) Enduring life strains.
Key question:
What are the most important problems that you have in your life at the moment, other than
finding food, shelter and clothing?
Probes, if needed:
Do you feel good about yourself?
Are you as physically strong as everyone else?
What are the most important things that you need right now to get by?
What arc your plans for the future?
Do you need more education? What kind of education?
Will you be able to find a job? What kind of job could you get? What type of training would
assist in getting the type of job you would like to have? What kind of job would you like?
• Where would you like to live?
« Do you often feel sad, lonely or unhappy?
• I lave you ever tried to harm or kill yourself?
•
•
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(d) Life transitions.
Key questions:
Have you had to move often? Do you need to move around a lot when living on the streets?
Why? Docs your family move around a lot? Why?
o
Probes if needed:
Did you grow up in a different place? What made you move here?
If you have moved, did you lose contact with close friends or family?
is it difficult to make new friends when you move into a new area?
What makes it easier to fit in with a new group of street children ?
Have you had different groups of friends? If so, why did you change your friends?
(e) Developmental changes of adolescence.
Key Question:
What things arc good and what things arc difficult about growing up and being an adolescent?
I
Probes, if needed:
® What is it like to be an adolescent? Are you like other adolescents? What is different about you?
© Do you worry about growing up? Do you worry about your size or appearance?
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Module 5 - Determining (lie Needs and Problems ol Street ( hildren
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Example
A street children project in The Russian I’edcration found asking, “Is it better to be a child
or an adult ?” got more response from boys than, “What is it like to be an adolescent?”. The
project also found that the questions about growing up and worrying about appearance
brought forth a lot of comments from girls when used in focus group discussions.
1
3. Noriiializalion of substance use.
Key question:
What problems concerning substance use are there in your community ?
Probes, if necessary:
• What do street children in your community think of substance use?
• Which substances are all right and which substances are bad to use? Which is the most harmful
substance and which is the safest?
• Where do street children get their substances from?
® 1 low easy is it for street children around here to get substances? Is it easier to obtain substances
here than elsewhere?
)
• Do stieet children piefer using certain substances or do they use different substances
depending on their availability?
• In what way has there been a change in the availability of different substances around here over time?
• I low much docs the cost of substances influence the type and amount of substances that street
children use? lias there been a change in the cost of the substances that they use?
• Do stieet childicn use more substances when they live on the streets or when they live elsewhere?
• Do most street children use the same substances as their friends? Do friends encourage others
around here to use substances? If so, why?
® Do street children get hassled by the police or others because of their substance use?
® Do you think that advertising, sponsorship or marketing of substances influences street children’?
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4. The Effects of substance use.
Key questions:
What arc the main reasons street children use substances? What effects do they gel from using A
substances such as cannabis, alcohol, tobacco, glue, etc.?
"
■
Probes, if needed:
©
What substances do you/strcct children use? Which is the favourite substance? Which is lhe
least favourite substance?
You may prompt from the following list:
G
Alcohol
Iobacco
Cannabis (c.g. marijuana leaf, hashish, resin/oil)
Natural opioids (c.g. heroin, opium, morphine, codeine)
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Synthetic opioids (e.g. methadone, pethidine, omnopon)
Cocaine (e.g. coca paste, cocaine salt, crack)
Amphetamine-like stimulants (e.g. methylphenidate, methamphetamine, MDA, ice)
(
• Stimulant/I lallucinogens (e.g. MDMA, bromo-DMA)
• Other stimulants (e.g. ephedrine, caffeine)
f
•
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Hallucinogens (e.g. LSD, psilocybin, peyote, mescaline, PCP)
Hypnosedatives (e.g. barbiturates, benzodiazepines, methaqualone)
Volatile substances and aerosols (e.g. petrol, glue, benzene)
Others (e.g. khat, kava, pitchuri, nutmeg, betel nut)
Prescription drugs
How often do you/street children use these substances?
How much of the substance do you/street children use each time? Do you/street children get intoxicated?
How do you/street children take these substances?
When did you/street children first start using these substances?
Why do you/street children take them? How do the substances affect you/street children? Do
you/street children enjoy them?
Where do you/street children prefer to go to use substances?
Who do you/street children use these substances with? Do you/street children use substances
when alone? Do you/street children share substances with others?
What do you/street children find is good/bad about taking substances?
What effect does taking substances have on your health or the health of street children ?
How do you feel about your taking substances?.
What does your family feel about your substance use? Or I low does substance use affect
family life around here?
How docs your substance use affect your friendships? Or 1 low does substance use affect friendships?
I low docs your substance use affect your study or work?
Have you/street children been in trouble with the police because of (your) substance use?
I lave you/street children had to leave a place you/they were living in because of your/ their
substance use?
Do you/street children go without things such as food or clothes so that you/they can buy substances?
Docs substance use affect your/someone’s sex life? Do you/street children usually have sex
when you/they take substances?
Have you/street children ever been in an accident after using substances?
I lave you/street children ever been in fights during or after using substances?
Do you/street children feel guilty about using substances?
Do you/street children need help because of (your) substance use? Would you/ street children
like help to do something about (your) substance use?
Has anyone told you/street children that you should do something about your/their substance
use? Do any of your friends have a substance use problem?
I lave you/street children ever been treated for a substance problem? C’an a person with a
substance problem be helped or cured?
How do you feel about street children who sell substances?
Module 5 - I Irin iiiinin;' Ihe Needs and Problems ol Sheet < hildrcn
5. Attachments.
Key Question:
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Who or what is most important to you?
Probes, if needed:
What is/ was your family like? Arc you still in contact with them?
What do you like about your family? What don’t you like about your family?
(If away) What do you miss about your family? Would you like to visit your family or go back
and live with them? Would your family welcome you back?
Who is most important to you in the family?
Whal arc your thoughts about school? (same for non-formal education) What is/was the most
useful thing about school?
How well did/do you do at school? (same for non-formal education) I low did/can you keep up
with the schoolwork?
How did/do you get along with your teachers? (same for non-formal education)
Would you consider going back to school? (same for non-formal education)
Do you have a few close friends, many not very close friends, or no real friends? Who is your
closest friend?
Whom do you trust? Whom don’t you trust? Who do you turn to when you need help?
Whom do you admire? Who is your hero?
Whom do you most agree with -your parents/carers, your friends, your tcachers/cmploycr, or
your sexual partner?
Whom do you feel most comfortable with?
Who admires you? Who says good things about you?
Who are you most like?
Do your parents/carers approve of your lifestyle? Do your parents/carers approve of your friends?
Do your friends approve of your parents/carers?
Do/did your parents/carers have a substance use problem? Did you leave home because of your
parcnts’/carcers’ substance use?
Did you leave home because of sexual, physical or emotional abuse?
Is religion important in your life?
Do you like your work?
What is your employer like?
Do you have a pct? How do you feel about your pct?
Do you own anything that is very special to you?
6. Skills, competencies and coping strategies.
Key questions:
What things do you think you arc best at? How have you managed to survive the difficulties
in our life?
©
©
Probes, iI” needed:
What are the most difficult problems that you have to deal with?
llow do you usually deal with these problems?
What could you learn that would help you cope belter?
What do you do when you feel anxious or stressed? What do you do when you feel sad or
depressed?
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What do you do when you feel angry? 1 low do you try to control your anger or violence?
Do you have any problems sleeping? What helps you to sleep?
What do you do to make you feel better about yourself?
I low do you try to stop street children from forcing you to do something you don't want to do?
What do you do to try to control your substance use?
What special skills do you need to work or to earn money?
7. Resources.
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Where do you get your information from? Who do you speak to and listen to? What
information do you trust? Who wouldn't you listen to or take notice of?
Where do you go for medical treatment? Do you feel comfortable there? Are you treated well
there? How could the service be improved? Who do you listen to about medical and health
information?
©
Who do you see to help you find shelter or a place to live?
Who helps you get food?
©
Where do you go to find clothing?
Where do you go for recreation? What do you do for fun? What would you like to do for
recreation? Do you play any sports? Would you like to play sports?
Where do you spend most of your time? Where would you like to spend time?
Arc you involved in any educational activity? If so, what arc you learning?
I lave you had any training for a job? I f so, where? What kind of training would you like? I low
would it be helpful?
© If you can read, what do you read and what would you like to read?
e Do you watch television, video, movies, or listen to the radio? Which do you trust, and which
provides you with the best information?
©
Do you read information pamphlets and posters? Do you believe them?
©
What kind of information would you take notice of, e.g. colourful, humorous, frightening, serious?
©
Where do you find out about information on substances?
©
Where would you go to get help for a substance problem?
©
Who could give you advice about your diet?
8. General health issues.
fi
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How has your general health been in the past?
What problems have you had with your health? Have you had any accidents? Do you sull'ci
from any allergies? Have you any problems with your teeth? Have you ever had a sexually
transmitted disease?
Do you suffer from any long term disability?
I lave you ever required medical treatment, e.g. for malaria, tuberculosis, parasite infection .’
Have you ever been admitted to a hospital? If so, why? Have you had any, operations?
I lave you ever been treated by a psychiatrist or psychologist? Why did you need such
treatment?
Are you receiving any treatment now? Arc you satisfied with your medical treatment? I low can
it be improved?
Has your substance use caused any problem w ith your health?
What immunizations have you received?
What do you normally eat? Do you think that this is a good diet? How could it be improved?
Module 5 - Dctenniniiin (lie Needs and Problems of Street ( liildren
9. Risk behaviours.
Key Question:
Example of asking question directly:
Do you take any risks with your life or safety? If so what type of risks?
Example of asking question indirectly:
Do you think street children take risks with their lives or safety? If so, what type of risks?
©
©
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Probes if needed:
Do you/street children around here do somewhat risky or daring things? How do you/street children
around here show oil Io your friends? I low do you/street children around here prove yourself?
What do you/street children around here need to do to be accepted by the other street children?
Do you/street children around here get involved in fights? Do you/street children here
carry/use a knife, gun, or other weapons? Do you/street children around here break the law for
lun, to be accepted by others, or to survive in the streets?
Do you/street children around here do risky things to earn money or to get food, clothes,
shelter, etc?
Are you/street children around here sexually active? Have you ever been forced to have sex?
Do you provide sex to survive? Have you ever had sex with a person of the same sex? How
many sexual partners have you had/havc now?
I lave you any children or have you been pregnant? I lave you ever had an abortion? If so, where?
What arc sexually transmissible diseases? What is HIV? AIDS? Have you ever had a sexually
transmissible disease? Are you/street children around here at risk of becoming infected with
HIV or with other sexually transmissible diseases ?
Do you use any form of contraception? What type? How often?
What is ‘safer sex’?
Do you/street children around here experiment with different combinations of substances?
What combinalions do you/strccl children around here use? Do you/street children around hcic
ever lake substances which you don't know about?
Do you/strccl children around here do risky things after using substances, such as committing
a crime, climbing buildings or trees, swimming, having sex with strangers, or walking across
a busy street?
Do you use substances alone or with other street children? Where do you use these substances?
Have you ever injected a substance? How did you inject it? If so, did you share the needle,
syringe, water, or any other utensils with someone else?
Where do you get your clean needles and syringes from? Do you re-use them'? I low do vou
clean them and with what?
Who would you ask to find out more about the substances you use, and how could you piolcct
yourself from any harm?
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Working W ith Strerl ( liihlien
Menu B: Service Provider.
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The second menu (Service Provider Question Menu) is for collecting data from adults who are
involved with street children. Questions to be asked of adults can also be asked in a focus group, an
interview, or a survey.
1. Demographic information.
®
•
•
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•
•
•
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What is the sex ratio of street children?
What is the age range and average age?
Where do they come from? Where do their parents come from?
What are the literacy and educational levels like?
Where do street children live, sleep, spend most of the day?
Where arc their parents? Who and where were they raised? Do they come from institutions?
What is their religious involvement?
Do they work?
Note: The term, ‘street children’ is used throughout the sample Menu Questions for Service
Providers. Remember the definition of street children used by the WHO Street C hildren Project on
substance use is broadly defined (see the introduction). You will need to adapt the term to fit your
local needs. For example, instead of street children, you may want to say “homeless childrcn”or
“children living in slums”. An organization in Canada, found that the terms “street kids” and “street
youth” were preferred.
2. Stress.
a) Major life events.
e
What kind of tragedies have street children been exposed to?
What disasters or major changes has the local community been exposed to?
c How was the community affected? How did the community respond?
o How have these tragedies and disasters affected the children? What help have they received to
cope with the trauma of these tragedies and changes?
<r» What major risks do street children have to contend with on the streets?
©
Arc streel children scared of being harmed? How or by whom?
Have street children been affected by any major illness?
e
b) l-veryday stresses.
e
1 low do street children spend each day?
What do they have to do to survive on the streets each day? What are their priorities?
What are the problems that they have to deal with? I low do they cope?
©
Where do they sleep?
©
How do they find shelter, food and clothing?
How do they keep clean?
I low do they pay for their basic needs, recreation and substances?
Arc street children involved in survival sex?
©
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Module 5 - Dclcrinining the Needs and Problems ol Street ( hildren
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c) Enduring life strains.
® What are the social, cultural, health, political, environmental, industrial and economic fl
problems of the local community?
<
® I low do these affect the street children? What arc the future prospects like for street children?
• What arc the main social factors which contribute to their homelessness?
® How do street children feel? Do they suffer from depression? What is their self-image and self
esteem like? How do they express their feelings?
® Do street children harm themselves or commit suicide?
d) IJfc transitions.
® How mobile are street children? What are their movements and why do they move?
© How stable are their contacts with their family, peers and health and welfare services?
© What kind of changes do street children experience? 1 low do they adjust to these changes?
e) Developmental changes of adolescence.
•
•
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•
What problems of adolescence do these street children experience?
Are these problems similar to other adolescents?
Are street children concerned about their size or appearance?
Do they understand the normal developmental changes of adolescence?
3. Normalization of substance use.
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What substance problems exist within the community?
o What substances are used in the community?
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What is the attitude of the community towards different substances, substance use and
substance users? What substance use is condoned and what substance use is not accepted b\
the community?
Do street children use substances?
How does the community influence substance use?
How easy is it to obtain both licit and illicit substances in the community?
Are substances more readily available for street children?
Do peers and families inlluence the substance use by street children?
1 low important is advertising, sponsorship and ‘pushing’ in influencing substance use by street
children?
I low arc street children who take substances treated by the police or other law enforcement officers'’
What strategies (c.g. health education campaigns) arc used in the community to prevent
substance related problems?
4. Substance use and its effects.
What substances do street children use? What arc the preferred substances? What combinations are used?
©
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Why do street children use substances?
How arc these substances used or what is the route of administration?
I low often do street children use these substances? I low many children arc dependent on substances',’
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Where arc these substances obtained from?
I low do they pay for them?
Where do they use these substances? Who do they use them with?
Do they sell substances?
What arc the main problems that they experience through their substance use?
What arc the greatest risks to street children through their substance use?
What arc the greatest concerns that the community and your organization have about the use
of substances by street children? Do street children cause problems for the community?
5. Attachments.
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What kind of families do street children have or come from?
Arc street children still in contact with their families? Do they miss their families?
Could they return home to live with their families?
What are the reasons for street children leaving home?
I low common is physical, emotional and sexual abuse in these families?
How do their families feel about their children living on the streets?
What problems do their parents have? Is it common for their parents to have a substance
problem?
Who are their friends? How strong are these friendships?
Whom do they trust? Who don’t they trust?
Whom do they admire? Who acts as role models for them?
Who admires them? Who gives them complements and positive messages? What are street
children good at?
How arc they valued in the community?
What has their schooling experience been like? Why have they left school?
6. Skills.
Competencies and coping strategics
What coping skills do street children use to survive on the streets?
n
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Are there positive learning experiences associated with living on the streets?
What arc the most difficult problems that they have to deal with?
I low do they cope with depression, anxiety, anger and fear?
Compared with other children, what living and coping skills do they lack?
How do street children learn new skills?
7. Resources.
o
Where do street children get their information from? What information do they trust? Who do
they trust as information providers? In what form is the information more likely to be accepted?
What information resources are available to them? Have any resources been specifically
developed for street children?
Where do street children go for medical treatment or advice? What medical services arc
available? How accessible are these services to street children? Is training offered to service
providers to improve delivery of services to street children? Has the training been evaluated?
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Module 5 - Dclei inininy (he Needs and Problems ol Street ( hildren
Are reproductive health services available for street children? Are condoms and other
contraceptives easily available to street children? Is testing for HIV and other Sc.xuallx
Transmissible Diseases (STDs) offered for street children? Is pre- and post-test counselling
available? Is treatment for STDs available? Is care and support available for street children who
are infected with HIV and those who have AIDS?
Where do street children go for advice or treatment related to substance use? What substance
treatment and advisory services are available to street children? What strategies are used? How
accessible arc these services for street children?
©
Are there any services specifically for adolescents? How are street children treated by these
various agencies?
Do any agencies provide a range of services in one location? What agencies provide an
outreach service? How are outreach services provided? Who utilizes the outreach services?
Where do those children go to find shelter? What kind of accommodation and accommodation
services is available? How accessible are these services to street children?
Where do street children go to find food? What services are available to feed street children?
How accessible arc these services to street children?
Where do street children get dressed? What services are available to provide clothes for street
children? How accessible arc these services to street children? Where and how do they clean
their clothes?
Where do street children go to wash? What services provide facilities for street children to
wash? How accessible are these services to street children?
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What do street children do for recreation? Where do they go for recreation? What recreation
services arc available for street children? How accessible are these services to street children?
©
Where do street children go to find formal and non-formal educational opportunities? What
educational services are available to street children? How accessible arc they for children'.’
What percentage of children are able to read, write, and do basic mathematics?
Where do street children go to find employment? What vocational training and employment
services are available to street children? I low accessible are these services to street children?
Where do street children go for counselling or emotional support? What counselling scr\ ices
are available for street children? How accessible are these services for street children?
©
Where do street children go for religious or spiritual guidance? What religious support is
available to street children? How accessible is this support to them?
©
Where do street children go for legal advice or support? What legal advice and rights arc
available for street children? How accessible are these services to street children? What human
rights abuses do they suller? Who abuses them?
©
Where do street children go for physical protection when they are threatened? What protective
services arc available to street children? How accessible arc these services to street children?
Arc there networks of community agencies which deal with street children? I low do these
networks operate?
Has any research been conducted or data collected on the problem of street children in the
community?
©
Where do agencies dealing with street children go for advice or support?
©
What exposure do street children have to the mass media, such as television and radio? What
mass media health education programmes arc available to street children?
Where do street children working with street children get their training from?
20
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8. General health issues.
What are the main health problems of these
street children? What type of long term disabilities do
street children surfer from?
•
•
•
•
•
What is (he prevalence of sexually transmissible diseases (including Hepatitis B & C HIV
infection, gonorrhea, syphilis) and other infections among street children?
How common are accidents and other trauma among street children?
How common arc psychiatric illnesses among street children?
Do street children suffer from nutritional disorders?
Do street children experience dental problems''’
What are the common health problems in the general community? I low do these problems dilfer
hom the problems experienced by homeless children? What factors contribute to these differences?
9. Risk behaviours.
What kind of risk behaviours do street children indulge in? Which of these behaviours pose the
greatest risk to the children and to the community?
P
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* shannTwi01;
Sllbstancc
group of children? How common is needle
sharing What knowledge do street children have of safer substance using practices? What arc
the gicatcst nsks to street children through their substance use?
I low common are unplanned pregnancies among street girls? I low
are these pregnancies managed?
What contraception is used by street children? What is their understanding of safer sex ^and
how widely is it practiced?
8
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e How common is survival sex/prostitution in
this group of street children?
Module 5 - Delcnninh.o i|le v .,Is
:I"<1 I’rolilems of Street ( liildren
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Learning Activity
311
1- kleiKifying assessment questions.
answered. The six p«s »r 11,0 M„dilic(l
*J ;'h;j v‘l“sl"”s
y<>“ »"«w lire I
general issues
"My be
y„llr Sltua|ion Write aserve
.O11S as a guide to the
the model.
area of :
depressed, anxiou^or lonely?S/d,'St,CSS
,'0W ,hC Ch‘ld reacts lo stress
eg- is !hc child
a,ld ^'^d^^dTth^mniuni^
222^^tanccs ‘yP^'ly have on stt^Tchfc
ss» sghsk
Street ch.klrcn’s competencies
©
^sources that are T.cces^ble
i’lil a star next to '^'"li’nmhonth;.! appear, nost , n u
(;1 „, , (, y( „,
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Working Willi Street < hildrei
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2. Asking questions.
Read the fol lowing conversation between a street girl and a street educator.
I
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
Educator:
Girl:
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“What made you decide to leave home?”
“I had to leave home.”
“Was there something special that happened to make you leave home?”
“My mother said I had to earn money”
“What did she need the money for?”
“To take care of the new baby.”
“How did you feel about having a new baby at home?”
“I didn’t like it. The baby cried all the time and my mother was tired.”
“What else changed when the baby was born?”
“After the baby was born, he slept with me on my mat.”
“Who slept with you?”
“Jose.”
“Who is Jose?”
“Mama’s friend. He’s the papa.”
“You must have been unhappy when Jose started sleeping with you on your mat.”
“He was nice. He bought me a new dress and a necklace.”
“I low did your mother like it when Jose slept on your mat?”
“She was angry. She said I had to go and earn money now.”
I low well do you think the educator asked questions? Give reasons.
Would you have asked things differently? Specify.
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Module 5 - Determining the Needs and Problems ol Street ( hildren
3. Asking open-ended questions.
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Try changing these yes/no questions into open-ended questions.
•
Do you always stay here?
Have you been sniffing solvents?
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Do you see your family?
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Now try to come up with at least 3 open-ended questions to find out the following information:
1. Why a street child ran away from home.
2. How a street child feels about living on the street.
3. Why a street child stole something from a youth centre.
©
[
©
©
24
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Lesson 3 - Methods for collecting information
3.1 Collecting information on street children.
A number of methods that have been used by the WHO Street Children Projeet are deseribed in this
lesson. One particular method. Focus Group Discussion, has been used extensively. Most of the
methods described in this module require considerable skills and knowledge. Either you should get
trained in the use of these methods of collecting information or engage people conversant with their use
to support you if required. You can get more information on their use from materials for further reading.
3.2 Focus Group Discussions.
A Focus Group Discussion (FGD) is an organized discussion among 6 to 12 individuals on a single
topic for a specified duration. It helps in the collection of qualitative (feelings or perceptions of target
audience) information. The process of group interaction stimulates active participation and
encourages ordinary dialogue (including differences of opinion) among, members of the group. The
assessment is better if the dialogue resembles a normal, serious discussion. The focus group technique
is especially useful for an in-depth exploration of street children's and service providers' views on the
given topic.
.1 focus ^roup discussion is tin
organized discussion among 612 individuals on a single topic.
Module 5 - !)e(ei inininj» the Needs and Problems ol Street ( hildren
Preparing lor Focus Group Discussions.
Steps that need to be kept in mind during the preparation for a focus group
discussion include:
® Decide what you want to know. It is not possible to discuss every
issue related to street children and substance use or sexual and
reproductive health in a single focus group. Decide what infor
mation you need to know the most. Make a checklist of the
general questions and probes. General or key questions allow
group members to reveal (heir general perceptions and attitudes
and specific questions or probes help to develop deeper
discussions of these perceptions and in understanding the
decision making process of group members. The list will remind
the facilitators during the discussion of all the issues that need to
be discussed. Ideally, at least one current or former street child
could be a part of the planning group for the FGD.
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Decide what you want to do.
® Identify the participants. The children themselves can answer many questions but, to get
a complete picture, organize a group discussion with service providers, community leaders,
ordinary residents, or law enforcers. Participants for these groups can be selected on the
basis of the questions that need to be answered.
1
© Characteristics of members of the street children focus group.
Determine whether you want street children with similar or different backgrounds in the same
group eg. vendors, sex workers, those using substances or at risk of sexual and reproductive
health problems. Girls should be separated from boys because they often do not speak much in
the presence of boys, especially if there are more boys than girls in the group. It is important to
get information about street girls because their lives are different from those of street boys in
several important ways. They may have more needs and may face more dangers than street boys.
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Characteristics of members of service providers focus group.
Invite members of the community who are in close contact with street children (such as
community nurses, doctors, social workers, community development officers, volunteers,
vendors who employ street children, parents, teachers, law enforcement officers etc.). Il is
often helpful to invite service providers from a range of different organizations. Mixing
participants from different organizations in the same FGD can promote an inlcrcshng
exchange of ideas and information and increase motivation to attend.
2(>
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® Plan the Focus Group Discussion.
©
©
©
Date and Time: Ensure that the timing of the discussion is convenient to all participants.
I he time that suits street girls may be different from the time that suits street boys. Choosing
an appropriate time may be particularly important for service-provider groups.
Confirm attendance: Keep in contact with the participants in person or in writing.
Venue: Arrange the meeting point. The place should be safe, comfortable and easily
accessible. It should offer privacy.
Presentation material/aids and seating arrangement: Prepare visual aids (flip charts,
writing materials, or art supplies). Make seating arrangements and place teaching aids in a
manner that promotes participation and communication, e.g. silting in a circle provides
better eye contact and improves communication.
Plan the focus group discussion: Identify the facilitator, observer and recorder, and fix the
duration (2 hours).
e
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• Roles of participants in Focus Group Discussions.
All participants of the FGD, have an important role in ensuring the quality and progress of the
discussion. The roles of various participants are given below:
• Facilitator: the facilitator should preferably be of the same sex as the l;(il) members,
should speak the same language and be familiar with the topic for discussion. Ideally, he or
she should have had the experience of working directly with street children. I he members
of the group must feel that the facilitator cares about them and their problems. It is best to
ask street children and service providers who they think would be a good facilitator for their
respective groups. The facilitator should:
- introduce the themes being discussed and create a conducive environment for discussions.
- establish confidence and trust among participants and ensure that each group member is
participating.
- control the group, keep discussion focused and help participants present theii ideas and
feelings to the group.
- protect members of the group from personal attacks, putdowns and criticism.
With a group of more than six street children or service providers it is better to have two
facilitators. A single facilitator might not be able to guide the discussion and pay attention
to the emotional needs of the participants at the same time.
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Module 5 - Determining the Needs and Problems of Street Children
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® Recorder: this should be someone who can prevent his or her own opinions from
influencing the information he or she records. The person must also have writing skills,
observation skills, and familiarity with the dialect or slang of the group. The recorder
should:
- note (he date and time of the meeting, number of group members, and (heir name and age.
- note the proceedings in the words of the group members so that other readers can actually
get the ‘feel’ of the discussion.
- from time to time help the facilitator by making suggestions on how to make the discussion
more meaningful.
- check the notes immediately after the discussion for completeness and accuracy.
Recording is a critical task because hearing the ‘voice of street children’ is the very purpose
of focus group discussions. Documenting only what is actually stated is a skill that can be
developed. One way to practice this skill is to simultaneously record the discussion on paper
and on an audio (or video) tape, and then compare the two.
y
• Observer: The person must have observation skills and should observe:
- the process of the discussion, the How of dialogue, the emotional atmosphere and problems
that hinder communication.
- nonverbal cues e.g. silence, restlessness and posture.
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How to conduct a Focus Group Discussion.
• Welcome the participants: welcoming the participants puts them at ease. A warm,
pleasant atmosphere will help street children and service providers relax, develop trust in
the other participants, and express their ideas. With street children, an introductory
activity that appeals to the group, such as a song, a prayer, or a brief game, will help get
the group started. You can do this with an adult group if local practices permit it.
■
!&,
> /!// introductory activity that
appeals to the yroup is useful!
& Start the discussion: state the general purpose of the FGD and explain the rationale and the
procedures. Ask the group for questions, suggestions, and expectations. Go over the basic ground
rules such as one person speaking at a time, respectful listening, or keeping what is said
confidential (not sharing what is heard in the FGD with others outside the group). Begin the
discussion with a general, open-ended question about the topic. Many street children projects have
found it best to start with less personal, non-threatening questions.
Facilitate the dialogue: pay attention to the process and the content of the discussion. The
process includes issues such as:
- who speaks and who does not.
- what topics are avoided.
- what issues upset the group.
- whether the pace of the discussion is slow or quick.
- how the participants interact with one another and with the facilitator.
Encourage the participants to share as much information and as many insights as possible, 'fry
to maintain an atmosphere in which participants take each other seriously. I lelp to make it sale
for participants to share the feeling behind their opinions.
29
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Module 5 - Determining the Needs and Problems of Street < hildren
r
Deal with tiredness and discomfort during the discussion: it is vital to be flexible with the
I CjD process with street children. Keep sessions short where needed. Do not ask too many
questions in each session. One may break the monotony through humour or a game. You could
offer snacks as an incentive if this suits your situation. I lowcvcr, incentives can have a negative
impact, for example, street children expecting payment or similar incentives associated with
any contact with researchers or street educators could result in having one organization having
an advantage over the other organizations who do not offer incentives although they still offer
quality services. Keep the emotional atmosphere of the discussion at a level that can be
tolerated by all the participants. If any of the members become too distressed, ask the group to
take a bicak while you address his/her feelings. Over time, you will develop your own ways to
keep the discussion friendly, comfortable and informative.
<n» Conclude the FGD: towards the end of the session, restate the objectives of the FGD and
summarize the main points made by the participants and ask them if the discussion has missed
any important issues or questions.
- Express sincere appreciation for the participants’ attention, time, and contributions.
If the information has not already come up in the course of the discussion, ask the participants to
answer a few questions about their background (age, education, and place of birth).
- Inform the participants of subsequent activities, if any.
End the 1GD with a feeling of togetherness. Sing a song, -shake hands, or do a similar
activity that affirms the group and puts a sense of closure to the time spent together.
©
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Important considerations during Focus Group Discussions.
® Barriers to effective Focus Group Discussions: In this WHO Children Project the
following barriers were identified.
Attitudinal problems such as uncertainty on the part of service providers as to why
they should participate in focus groups and how their input would benefit their work
or help the community. Some centres have faced quite a lot of difficulty in recruiting
service providers to participate in such discussions.
Problems of logistics, such as finding convenient times and places to meet.
Carefully consider the best way to approach and involve service providers in your area. Developing
basic community support for the project and an open discussion on practical issues and concerns
(c.g. roles, responsibilities, funding etc.) may remove some of the barriers.
©
(
Incentives tor participation in FGDs: in Honduras, participating street children were taken
out tor a pizza after each meeting. In the Philippines when the children participated in the FGD
they were given a bag of rice. Children who returned home often gave the rice to their family,
whereas those living on the street traded the rice at restaurants or shops for food. Another
strategy is to offer transport to the meeting. Incentives may have negative implications for
future activities if they arc not maintained. Determine incentives based on available resources.
30
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3.3 Case Studies.
A case study is a detailed description of one person’s or one group’s experience with an issue, e.g. a
description of how one street child began experimenting with substances, became a heavy user, and
then stopped using the substance. Case studies help to put pieces of information into their proper
perspective and they make a greater emotional impact than do statistical data.
Case studies arc particularly useful for describing individuals or subgroups which do not fit the
typical pattern of behaviour. If there are very few street girls in your area, do case studies of some
of the girls, rather than studying them as a group. Case studies on particularly resilient street children
could help in the identification of healthy strategies for survival on the streets.
3.4 Observation.
Using this method, an observer watches a specific group of street children or a specific location
while trying not to attract much attention. The person records as many observations as possible in
a field diary. The observer might record everything he or she sees in a ‘free-flowing style,’ or he/
she may concentrate on specific behaviours that have been decided in advance.
Observation is a good technique for coming up with new ideas about the lives of street children
which could be tested later. It is also a good way to validate (confirm) the data collected by
interviews or questionnaires. Safety issues must be considered, if the investigator is observing illegal
activities.
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PB O 3 3 D
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Ohservalion is a good lech/iique oj"coming u/) with
new ideas about the lives oj street children.
It
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Module 5 - Dclci ininiiig (lie Needs and I’loldems of Street ( hildren
3.5 Key Informant Interviews.
A key informant study is a series of interviews with several key individuals or experts on a topic.
Key informants arc individuals with first hand information about street children. These individuals
can be resource persons in the government, health facilities or other service organizations in the
community. I he same questions arc asked during all the interviews, but the interviewer is free to ask
follow-up questions in order to get as much information as possible from the informant.
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The following could be the experts on the subject of substance use and sexual and reproductive
health among street children: former street children, cx-substance users, parents of street children,
drug dealers, sex workers, employees of street children projects, social workers, health workers^
sticct cducatois, teachers, researchers, religious leaders and community leaders.
® How to ensure an effective key informant interview.
Identify key informants.
Inform the community or organization about the interviews.
Contact individuals to be interviewed well in advance.
Arrange for adequate translation if language barriers exist.
Provide adequate information to the contact persons c.g. purpose and objectives of the
project, length of interview etc. Prepare a relatively formal outline with the questions you
may want to ask and be prepared to take careful notes.
© Observe existing cultural norms.
® After the field visit analyse and discuss the findings with relevant people, c.g. key
informants, street educators, and administrators.
®
©
®
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3.6 The narrative research method.
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This technique is especially designed to study the sequence of events that are involved in a
behaviour. It is a good method to study topics where processes, rather than simple single behaviours
have to be assessed. l;or example, learning to use substances, making the transition from home to
street, deciding to have sex while under the influence of substances etc. could be studied with the
narrative method.
In narrative research, the subjects of the study create realistic stories about something that takes
place in their normal environment. Street children can be asked to make up stories about ordinary
street children. In a group setting, street children can be asked to role play (details of role play are
provided in Module 7: reaching street children) various characters to assist in the development of
a detailed story-line regarding the pattern of events that lead to the end point under consideration,
for example, a street child’s decision to use a substance for the first time.
A questionnaire can be developed on the basis of the story. It can be administered to other street
children in the area, and information about the process of starting and continuing the use of
substances can be obtained.
Mote injoi-nuitioii on case sfm/ies, observation and key informant studies can be fotnid in a WIK)
document -Qualitative Research for Health programmes, document no. MN!l/PSb/94.3
Narrative method helps to study a sequence of
of events in a behaviour.
33
Module 5 - Delermininy (he Needs and Problems ol Street ( hildren
3.7 Surveys.
Surveys can provide more detailed information than the key informant interviews. A survey is a
questionnaire or interview given to a relatively large number of street children, service providers,
families, or others. I he exact questions and the range of responses are set in advance. Surveys arc
useful when numerical data about a topic is needed, for example, the number of different substances
used by street children. Surveys can help in the comparison of results from ;a given assessment to
data about other assessments and settings. Quantitative information that surveys provide may be
required for interventions that have to do with the community rather than an individual street child.
A donor organisation may also ask for such data when they have to provide funds for activities.
® How to prepare a tool for survey.
A questionnaire that has already been written and used in other assessments can be used to col
lect information. This helps in saving time and in comparison of results from the assessment
with data about other groups and settings. If information is required on issues on which
pre-existing questionnaires are not available, you can develop your own questionnaire. The
steps involved in the development of questionnaires are given below:
1) Identify main questions for which quantitative
information is needed (c.g. knowledge about risks,
awareness about condom use, substance use, and
reasons for using substances).
2) Develop questions using words that are
understood in the local culture, c.g. for condoms,
sex, substances and other sensitive topics. It is
important that the words used are accurate.
3) Test the questions among a group of street
children or health care providers.
4) Modify the questions based on the test.
5) Add an introductory note on the purpose and
method of assessment. This helps in allaying
apprehension regarding the assessment in the
minds of the subjects.
Surveys provide more detailed information
than key informant interviews.
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3.8 Projective methods
Projective assessment methods allow participants to express their thoughts and feelings in an
unstructured, creative, and often nonverbal way. One of the most popular projective methods that
researchers use with children is drawing. Instead of asking children to vet bally describe their
families, the investigator could ask them to draw a picture of the family. The children project
thoughts and feelings onto the paper. The person collecting the information should discuss the
drawing with the child immediately afterwards to be able to understand the message the child is
conveying in the drawing. Use of projective methods require training in psychology, because of the
complexities involved in the individuals productions (c.g. drawings), which make the task of
interpretation difficult.
Example
Street educators and researchers in Bolivia have experimented with a more contemporary
version of projective drawings. They have given cameras to street youths who have then
documented their own activities by taking photographs.
It is important to remember that many street children may not want their activities recorded
on film, regardless of whether the activities are legal or illegal. Gang members, corrupt
police officials or drug traffickers may try to harm street youths who draw them or take their
picture. So, these need to be used judiciously.
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Module 5 - Determining (he Needs and Problems of Street Children
Learning Activity
I. Methods for collecting information:
o
Make a list of important areas for which you need to collect information. Against each area,
list the most appropriate method for collecting the information.
Areas
Method
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2. Questions for focus group discussion. ( Refer back to the menu of questions.)
•
Develop at least 4 questions that you could ask street children in relation to substance use
and sexual and reproductive health during focus group discussions.
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Develop at least 4 questions that you could ask service providers in relation to substance use
during focus group discussions.
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3. Surveys.
•
36
Develop 7 questions you could ask street children during a survey on their backgound.
Working \\ ith Street ( hikh < u
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___ Lesson 4 - Analyzing information and
preparing an Action Plan
Information that has been collected has to be interpreted (analyzed) before it can be used effectively
for developing or modifying the programme. Since the focus group discussion method was
extensively used in this project, the example on analysis of information will be on this method only.
Consult local experts on how other information on various methods could be analyzed.
4.1 Analyzing information from a Focus Group Discussion.
® Collate the responses.
Make a list of statements or responses to a given issue or question.
Record the number of times a particular response was given. Avoid
making quantitative-numerical conclusions about the topic on the basis
of the FGD.
Even at the time of collation of responses, it is important that the exact
words of the participants be documented. This gives other readers an
opportunity to make their own conclusions about what a child really
meant to communicate by a certain statement. If the same questions
were put before more than one group of participants, the data for each
discussion should be analyzed separately to bring out the similarities
and differences in views expressed by different groups.
• Study FGD responses to develop conclusions.
Analyze information before develo/)iny
or modi/yiny a programme.
Tentative conclusions regarding the needs of street children, services provided and the services
which need to be developed or improved should be reached after studying the responses made
in FGDs. These should be reviewed with a small team composed of street educators, members
of the Community Advisory Committee, street children, and programme managers. The
conclusions drawn will help in making decisions about the need to start, adapt/develop or
discontinue interventions.
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® Give feedback to the participants.
Providing feedback about the discussion can itself be an effective intervention. It demonstrates
that you believe that the ideas and opinions of the participants are important. Feedback also
encourages the street children to think further about their lives, needs, and involvement with
substances and other risk behaviours.
Tell them about the data and offer your conclusions by calling the group together again,
sending a written description to those who can read or by speaking to members individually.
The accuracy of the data should be confirmed and the participants should be asked lor their
interpretation and for additional ideas to deepen the analysis of the results. A brief report of
these discussions should be written.
Module 5 - Delcimining (he Needs and Problems ol Street Children
Example
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Iloiiduras:
The initial results of the focus group discussions are given to all the staff and volunteers of
an established street children project in Honduras. It has been found that after this briefing,
the project team discussed the information and considered various issues needing immediate
attention or further assessment. As the project has been in operation for some time, FGDs
were used to collect information about the on-going needs of street children, identify any
changes in their substance use patterns, and monitor their responses to the project activities.
1
4.2 The Action Plan.
The team should find ways to implement various activities on the basis of the analysis. Ask the
following questions to develop an action plan:
e What problems should be given higher priority?
Which problems can be corrected easily?
Which activities should be started or improved?
i
Are adequate resources available?
For the action plan to be relevant, it must be specific to the identified needs or problems, and it
should incorporate short-term and long-term goals and objectives. The plans should be updated
regularly to take into account the changing nature of street life, the current availability of resources
and services, developmental issues, and the fluctuating motivation of street children.
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Learning Activity
1. Developing an Action Plan:
An action plan form has been provided to guide you. This format could be used in your
programme or it might have to be adapted further to suit your context.
ACTION PLAN
Target
Group
Causes of
risky
behaviour
(Findings)
Objcclivc(s)
Type of
intervention
Street children
do not know
the
consequences
of unprotcccd
sexual
activities
Provide
information
on risks of
unprotected
sexual
activities
Identification of
Information,
education and
messages
communication
Message
development
Specific
activities and
Strategy'
Resources
Placc/site of
intervention
l iine frame
Posters
Shelter for
street
children
Januaiy 2001
onwards
(Example)
Street
Children
Selection of
media of
communication
Resource
mobilization
Information
dissemination
Street girl
She needs
condoms to
prevent
sexually
transmitted
diseases and
pregnancy
?
?
?
Video if
available
Street
children
Any other
convenient
place
Professional
personnel
Interested
community
members
?
?
?
Complete the missing information on the street girl.
2. As a group, share experiences on the barriers and limitations you have faced in trying to
address the needs of street children in relation to sexual and reproductive health issues.
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Module 5 - Determining the Needs and Problems ol Street Children
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Bibliography and further reading
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UNICFF (1888). Methodological Guide on Situation Analysis oj'Children in Especially Uijlicull
Circumstances. Lima, United Nations Children Education blind. (Methodological Scries, no. 6).
WI1O (1996 ). Street Children, Substance Use, and Health: Monitoring and Evaluation oj Street
Children Projects. Geneva, World Health Organization (WHO/PSA/ 95.13).
WHO (1997). Coining oj age: TTom Tacts to Action j'or Adolescent Sexual and Reproductive Health.
Geneva, World Health Organization (WHO/FRH/ADH/97.18).
W HO (1993). The Narrative Research Method: .1 Guide to It s I'se.
Organization! A DI 1/W'l 10/93.4).
(icnc\ a. Wot l<l I Icalih
WHO (1994). Qualitative Research J'or Health programmes. Geneva, World Health Organization
(MNH/PSF/94.3).
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