A One-Way Street?
Report on Phase I of the Street Children Project
Part 4 of 9
This report is reprinted in nine parts with permission of the World Health Organization, Programme on Substance Abuse, 1993. The document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated in part or in whole, but not for sale nor for use in conjunction with commercial purposes.
The views expressed in documents by named authors are solely the
responsibility of those authors.
WORLD HEALTH ORGANIZATION
For development and implementation of the Street Children
Project, seven developing countries were selected to represent a
range of cultures and regions: Brazil, Egypt, Honduras, India,
Mexico, the Philippines, and Zambia. All WHO regions, apart from
the WHO European Region (EURO), are represented. Each of these
countries had a representative, selected on the basis of prior
contact with PSA, at a meeting at WHO in Geneva during 3 to 7
February 1992. Canada joined the project at a later time.
The criteria used to then select the participating
organizations/individuals in those countries were:
a) to be an organization (nongovernmental or government) which
provides a direct service to street children, including those who
use drugs; to be flexible and to recognize that it would benefit
from receiving support in dealing with street children who use
b) to have extensive and current practical experience working
with street children
c) to have a capacity to conduct basic research
d) to have a capacity to train other people working with street
e) to be recognized and respected by the local community within
which it works
f) to agree in principle with the project aims and objectives
g) to be receptive to the trialing of a new model for the
assessment of the local situation and planning for an appropriate
a) to have clearly identified a gap in services for street
children who use drugs
b) to have no strategic plan or formal intervention developed for
the management of street children who use drugs
c) to be a relatively young organization with limited support,
but credibility and respect in the community.
PROGRAMME ON SUBSTANCE ABUSE
CH-1211 Geneva 27
Tel 791. 21.11
4. THE STREET CHILDREN PROJECT
WORLD HEALTH ORGANIZATION
For development and implementation of the Street Children Project, seven developing countries were selected to represent a range of cultures and regions: Brazil, Egypt, Honduras, India, Mexico, the Philippines, and Zambia. All WHO regions, apart from the WHO European Region (EURO), are represented. Each of these countries had a representative, selected on the basis of prior contact with PSA, at a meeting at WHO in Geneva during 3 to 7 February 1992. Canada joined the project at a later time.
The criteria used to then select the participating organizations/individuals in those countries were:
a) to be an organization (nongovernmental or government) which provides a direct service to street children, including those who use drugs; to be flexible and to recognize that it would benefit from receiving support in dealing with street children who use drugs
b) to have extensive and current practical experience working with street children
c) to have a capacity to conduct basic research
d) to have a capacity to train other people working with street children
e) to be recognized and respected by the local community within which it works
f) to agree in principle with the project aims and objectives
g) to be receptive to the trialing of a new model for the assessment of the local situation and planning for an appropriate response.
a) to have clearly identified a gap in services for street children who use drugs
b) to have no strategic plan or formal intervention developed for the management of street children who use drugs
c) to be a relatively young organization with limited support, but credibility and respect in the community.
The meeting in Geneva during February 1992, agreed to the following aims, objectives, outcomes and methodology.
The overall aim of the project is:
To improve the health, welfare and quality of life of street children in the selected sites. It recognizes that many NGOs have well researched and developed strategies in existence and aims to build onto and further develop these where they exist.
The specific aim of the project is:
To facilitate the work being done by existing agencies which currently provide services for street children, with a particular focus on improving strategies for the prevention, assessment and management of drug problems in this population.
The project aims:
a) To assist local organizations in identifying the needs of street children.
b) To assist local organizations in planning a coordinated and holistic response to the identified needs and thereby develop appropriate prevention and treatment strategies.
c) To facilitate local organizations to develop and/or strengthen structures which will involve the local community, and particularly street children, in the development and implementation of local projects.
d) To facilitate the work of local organizations in improving the accessibility of primary health care and welfare services for utilization by street children who use drugs. To identify those obstacles which impede access to these services for youths, and to ensure that this population is not discriminated against.
e) To facilitate, through training, an improvement in the skills of health care workers and other community members in dealing with the health problems of street children, particularly the problems related to drug use.
f) To improve the community's attitude towards and understanding of the problems of street children through the activities of the local organization, and therefore reduce the likelihood of discrimination of this population, particularly for those who use drugs.
g) To promote the utilization of operational research, as feasible, in order to facilitate information gathering and project management.
h) To promote the use of empowerment methodologies by local organizations as an important mechanism for dealing with the drug problem among street children.
In working towards the aims of the project, the following objectives were agreed upon.
a) The identification of and collaboration with appropriate agencies, which work with street children in the communities being targeted, for the implementation of the pilot project.
b) The establishment of a community advisory committee at each site with representation from services which work with or are in contact with street children, local welfare and other agencies involved in emergency relief, housing, education and vocational training; local medical and other health care services; the criminal and/or juvenile justice system; the local community including the business sector; and street children themselves.
c) The development of a mechanism for establishing representative focus groups of street children and a structure within which these groups may be conducted.
d) The development of a strategic plan for the coordination of activities (including prevention, treatment and rehabilitation) directed at improving the health (in its broadest sense) and welfare of the local population of street children.
e) The formal or informal engagement of an appropriate local medical service, by the local organization, to provide primary medical care to the population of street children.
f) The development of an advocacy role for the community advisory committee with the purpose of:
g) The development and utilization of operational research methods, as far as possible, to test the alternative methodologies of intervention.
h) The development and utilization of empowerment methodologies by local organizations where appropriate.
a) The establishment of an effective model which may be used to assess the needs of street children in relation to drug use and to structure an effective response.
b) The establishment of a strong and influential network of individuals and agencies who work with or come into contact with street children.
c) Improved advocacy for the population of street children who use drugs.
d) The development of local strategic plans to address the problems of street children, particularly in relation to drug issues.
e) The establishment of a mechanism for consultation with street children.
f) The identification of innovative and appropriate mechanisms for the assessment of street children and for delivering outreach health services to them.
a) An increase in the number of contacts and quality of contacts between street children and health and welfare services, particularly for those street children who use drugs.
b) An improvement in the health of street children, including a reduction in problems associated with drug use.
c) An improvement in the community's perceptions of the problems of street children, particularly those related to drugs.
d) An increase in the confidence and competence of health and welfare workers in the management of drug problems of street children and therefore, a reduction in the perceived need by these workers to refer this group of street children onto specialist services.
The following guide was developed to assist in the site implementation of the methodology.
The site representative who attended the Geneva meeting was to convene a meeting with local staff to discuss the Geneva workshop and the strategy for implementation. Where possible all site staff were to have access to the documentation prepared by PSA and the meeting participants.
A separate meeting, a training workshop, was to be held for staff directly implementing the project, to cover the Geneva material in more detail and to provide additional training as necessary, for example in group work techniques and referral procedures. It was recommended that, given limited resources, staff already working with street children and who have some level of rapport and trust developed with them would be the likely ones to implement the project.
Focus groups are a form of Rapid Assessment, and are regarded as very useful in obtaining information quickly from specific populations. They are particularly useful in assessing a situation, determining the needs and attitudes of the population under focus, and for planning appropriate interventions and responses. They are usually easy to organize, flexible, and through open-ended questioning allow for issues raised by the group to be elaborated and followed. They often elicit information which could not otherwise be disclosed through the use of other methods, such as questionnaires. However, they also raise issues of trust in the group and, without effective leadership, can be open to manipulation by high-status group members.
Often, a number of focus groups need to be conducted with the same group of participants to increase trust, to obtain useful information on a broad range of issues, and to take into account fatigue, and the short attention span and concentration difficulties of some participants. Parallel focus groups with different participants can be conducted to increase the sample size, to cross-check for reliability and validity of information, or to highlight differences within a group, or sub-group, that may have important implications for the development of interventions and responses.
On-going focus groups can be used to monitor a situation and to assist in the evaluation of a project, especially by highlighting changes which need to be made to strategies. These changes may be needed to take account of broader social, cultural or political changes which impact on the strategy, or smaller, local ones which may have gone unnoticed. This process forms part of action or operational research, ensures that the project maintains relevance, is focused and monitored. It is also empowering, as participants see that their views are valued and become a part of the ongoing development of the interventions.
The success of any focus group will depend on the skill of the facilitator. It was recommended that they be carefully chosen, have contact with street children, be trusted by them, and have group work skills, for example, be able to lead a discussion, keep it focused, deal with emotional issues that may arise, be supportive and nonjudgemental, and be able to record the discussion in the least obtrusive and threatening manner. The facilitator should also have a good knowledge of the project, the participating organization, referral resources, the local community and its culture and customs. The facilitator must ensure that what is recorded and observed truly reflects the discussions of the group, and the consensus and differences that emerged. To enable this, the facilitator should feedback to the group their observations for verification by the group. This is also part of the empowering process.
It was recommended that the above issues be taken into account when setting up focus groups.
It was recommended that an initial focus groups be conducted with groups of street youth known to the participating organization. They should involve a range of street children, particularly those who use drugs. The purpose of these groups was to determine the types of services utilized by this population, the people and organizations they regularly come into contact with, the services they would be prepared to utilize, and their perceptions and attitudes toward various individuals and organizations in the community. The information from these groups would assist in selecting people who could be approached to become members of the Community Advisory Committee and of the Service Providers Focus Groups. Later, the formation of focus groups with less attached street youth would be necessary to obtain a broader information base. Some form of encouragement to participate may be necessary, such as an outing or the provision of food.
The setting for the group also requires special attention, and preferably would be a familiar and safe venue. Six to ten participants per group was considered to be the optimal size of such a group.
Utilizing the information obtained from the initial focus groups, the participating organization would be able to determine the most appropriate individuals and organizations who could be invited to become members of the Community Advisory Committee. It was recommended that the Community Advisory Committee membership should reflect those services the street children use or see a need for. Membership should also extend to those services that have a key role in dealing with or making policies relating to street children, such as police, juvenile justice system, local and state officials, and community leaders.
The purposes for establishing a Community Advisory Committee are: to share information, skills and ideas; to increase cooperation and enhance referrals; to provide support for the project; to influence community attitudes; to form a larger and more powerful body to advocate for the needs of street children, and to give a sense of "ownership" of the project to the community.
The Community Advisory Committee would determine its own terms of reference, relevant to the local situation. Part of their role should include attempts to safeguard the rights of street children, as outlined in the United Nations Convention on the Rights of the Child, including the rights to receive adequate food, shelter, health care, educational and vocational opportunities, criminal justice, love and respect.
It was also recommended that a focus group be conducted with professional and non-professional workers who provide services and employment to street children (including health, housing, educational and recreational services) and with people who are in daily contact with street children (e.g. vendors and community members). This focus group, or series of groups, should utilize the " Service Providers Issues and Questions Menu", contained in the document "Annex 6: Focus Groups" prepared by PSA for the Geneva meeting, which presents questions related to key topics. The key topics relate directly to the six variables of the Modified Social Stress Model adopted for the project; namely: Stress, Normalization of Drug Use, Drug Effects, Attachments, Coping Strategies and Skills, and Resources. The Community Advisory Committee may be an appropriate and convenient group of service providers for this task. However, if there are too many administrators as members of the Community Advisory Committee who are not currently, or who have never been, service providers, another group or a series of groups may be more appropriate.
It was recommended that soon after the Community Advisory Committee had been convened, a workshop for the Committee be conducted, if the Committee was not used as the initial service providers focus group. This workshop could take the form of a focus group and utilize the Service Providers Issues and Questions Menu.
Utilizing the information obtained from the young persons initial focus group(s), the service providers and/or the Committee members focus groups, it was recommended that the Committee, in collaboration with the participating organization and street children themselves, should develop a preliminary strategic plan. This plan should address, in particular, the problems associated with the use of drugs by the street children targeted, their needs, the gaps in services, and the obstacles identified. The Committee should also attempt to formulate their plan in line with the Modified Social Stress Model, and in a manner which allows for evaluation of specific, clearly defined outcomes.
It was recommended that further focus groups should be undertaken with a wider range of street children, particularly those who use drugs. The format for these groups would be to more closely follow the "Street Children Group(s) Issues and Questions Menu" contained in "Annex 6: Focus Groups" prepared by PSA for the Geneva Meeting. As mentioned in that document, these groups themselves are a form of intervention and, again, it is stressed that the facilitator needs to be skilled group work, capable of dealing with sensitive issues and emotions, and have a capacity to refer where necessary.
It was also recommended that the information from these groups should be fed back to the Community Advisory Committee as soon as possible, as it will have a significant impact on future plans and direction.
It was recommended that by utilizing the information from the various focus groups and the framework of the preliminary strategic plan, a Strategic Plan would be developed. This plan should cover both prevention and management strategies, and be able to fit into any overall strategic plan of the participating organization.
The plan should contain specific objectives and expected outcomes to enable easy monitoring and evaluation, and strategies for addressing service gaps and needs identified. The document "Annex 7: Intervention Options" prepared by PSA for the Geneva Meeting, which adopts the format of the Modified Social Stress Model provides a range of interventions which participating organizations might wish to consider. Piggy-backing interventions onto services which street children use and trust is likely to increase the penetration and effectiveness of any intervention.
The plan should also identify those who are responsible for each intervention strategy. For example, street educators, primary health care providers, administrators, local leaders, government authorities or departments.
It was recommended that any Strategic Plan should be a living document, which is constantly reviewed, improved and fine-tuned. The on-going focus groups can provide useful information to assist in this monitoring process, as can reconvened service provider or Community Advisory Committee focus groups.
It was also recommended that the engagement of an existing primary medical service, if not already part of the participating organization's network, should be a central part of the Strategic Plan. If not already providing an outreach service targeting street children, this primary medical service could be encouraged to do so as one of the objectives of the plan.
Organizations that serve the needs and interests of street children were strongly encouraged to develop clearly stated policies addressing the type and quality of services that should (or should not be) provided to street children by the organization. The written policies might address such issues as:
Without well documented policies to address such issues, staff will not be able to act with confidence in matters that are inherently controversial or that may conflict with community standards. Additionally, without written policies, staff may unknowingly act in ways that are not considered appropriate by the organization decision-makers.
Given that the model and methodology adopted for the project may be new or confusing to some, site visits were seen as essential. Site visits can play a vital role in strategy development and implementation by providing an objective participant who can clarify issues, bring information from other participating organizations, provide a sense of connectedness, validate the efforts of participants, and inject energy and optimism into most difficult work with a hard to reach and engage population of street children. This can assist in reducing the degree of isolation and marginalization experienced by some individuals and organizations, and can highlight some un- or under-recognized practices which warrant attention and validation. Site visits can assist in project evaluation and focus. The PSA Consultant who conducted the visits, was seen to be an appropriate person to fulfil this role, and the one site visitor to all participating organizations allowed for more connectedness and sharing of information and strategies. Some comments on the site visits included:
"The people you met in the different agencies and barangays were much impressed with your visit. It is not often that they get visited by someone from an international organization. Your visit gave them a sense of being recognized and appreciated for the work they are doing." (from letter to PSA by the Philippines principal investigator)
"Your brief visit has stimulated all of us connected with the project, and you would be pleased to know that the project has gained further momentum." (from letter to PSA by the Indian principal investigator)