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Causes of Child and Youth Homelessness in Developed and Developing Countries A Systematic Review and Meta-analysis Lonnie Embleton, MPH; Hana Lee, PhD; Jayleen Gunn, PhD; David Ayuku, PhD; Paula Braitstein, PhD
IMPORTANCE A systematic compilation of children and youth’s reported reasons for street involvement is lacking. Without empirical data on these reasons, the policies developed or implemented to mitigate street involvement are not responsive to the needs of these children and youth.
OBJECTIVE To systematically analyze the self-reported reasons why children and youth around the world become street-involved and to analyze the available data by level of human development, geographic region, and sex.
DATA SOURCES Electronic searches of Scopus, PsychINFO, EMBASE, POPLINE, PubMed, ERIC, and the Social Sciences Citation Index were conducted from January 1, 1990, to the third week of July 2013. We searched the peer-reviewed literature for studies that reported quantitative reasons for street involvement. The following broad search strategy was used to search the databases: “street children” OR “street youth” OR “homeless youth” OR “homeless children” OR “runaway children” OR “runaway youth” or “homeless persons.”
STUDY SELECTION Studies were included if they met the following inclusion criteria: (1) participants were 24 years of age or younger, (2) participants met our definition of street-connected children and youth, and (3) the quantitative reasons for street involvement were reported. We reviewed 318 full texts and identified 49 eligible studies.
DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent reviewers. We fit logistic mixed-effects models to estimate the pooled prevalence of each reason and to estimate subgroup pooled prevalence by development level or geographic region. The meta-analysis was conducted from February to August 2015.
MAIN OUTCOMES AND MEASURES We created the following categories based on the reported reasons in the literature: poverty, abuse, family conflict, delinquency, psychosocial health, and other.
RESULTS In total, there were 13 559 participants from 24 countries, of which 21 represented developing countries. The most commonly reported reason for street involvement was poverty, with a pooled-prevalence estimate of 39% (95% CI, 29%-51%). Forty-seven studies included in this review reported family conflict as the reason for street involvement, with a pooled prevalence of 32% (95% CI, 26%-39%). Abuse was equally reported in developing and developed countries as the reason for street involvement, with a pooled prevalence of 26% (95% CI, 18%-35%). Delinquency was the least frequently cited reason overall, with a pooled prevalence of 10% (95% CI, 5%-20%).
CONCLUSIONS AND RELEVANCE The street-connected children and youth who provided reasons for their street involvement infrequently identified delinquent behaviors for their circumstances and highlighted the role of poverty as a driving factor. They require support and protection, and governments globally are called on to reduce the socioeconomic inequities that cause children and youth to turn to the streets in the first place, in all regions of the world.
JAMA Pediatr. 2016;170(5):435-444. doi:10.1001/jamapediatrics.2016.0156 Published online April 4, 2016.
Editorial page 419
Supplemental content at jamapediatrics.com
Author Affiliations: Author affiliations are listed at the end of this article.
Corresponding Author: Paula Braitstein, PhD, Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7, Canada ([email protected]).
Research
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T here are vast numbers of children and youth in the world who find themselves connected to the streets. Owing to the difficulties of counting and defining this very fluid
population, no accurate estimates exist on the numbers of chil- dren and youth spending a portion or majority of their time on the streets; however, they are estimated to be in the tens to hundreds of millions.1
A variety of definitions have been put forth to define chil- dren and youth with street connections. Previously, the United Nations Children’s Fund broadly defined these children and youth as “[a]ny girl or boy who has not reached adulthood, for whom the street in the widest sense of the word, including un- occupied dwellings, wasteland, and so on, has become his or her habitual abode and/or source of livelihood, and who is in- adequately protected, directed, and supervised by responsible adults.”1(p9) A further categorization placed these children liv- ing and working on the street into 3 categories: children of the street (those who spend both days and nights on the street with limited or no family contact), children on the street (those who spend a portion or majority of their time on the street while re- turning home to a family/guardian at night), and children from street families (children from families living on the streets).1 In very high-income settings, youth connected to the streets are typically defined by their residential instability and precarious living arrangements, and they are referred to as homeless youth, runaway youth, system youth, or throwaway youth.2 Most re- cently, the term street-connected children and youth has been used to refer to those for whom the street is a central reference point—one that plays a significant role in their everyday life.1
While no clear definition encompasses the situations of all chil- dren and youth connected to the streets, it is important to un- derstand that their circumstances are fluid and that the streets play a central role in their lives.3 It is also important to under- stand that children and youth connected to the streets are rights holders3,4 who often find themselves in situations that violate their basic human rights.1,4
It is suspected that the dynamics driving this phenomenon (ie, street involvement of children and youth) are diverse and consist of complex pathways that vary between developed and developing countries, within geographic regions, by sex and age.1,3 However, the literature lacks any systematic compilation of children and youth’s reported reasons for street involvement, and there is an absence of consensus among academics, policy makers, stakeholders, and international organizations regard- ing these factors.1 Without empirical data on these reasons, policies are developed or implemented to mitigate street in- volvement without taking these causes into account. Often in resource-constrained settings, the prevailing paradigm assumes that children on the street are predominantly juvenile delin- quents, and the government response is often characterized by social exclusion, criminalization, and oppression by police and civic authorities.5 Strategies frequently involve violent street sweeps conducted by police with children being placed in overcrowded detention centers or repatriated to unsafe care environments.6,7 Many of these children subsequently return to the streets. Resource-constrained settings typically lack well- established child protection systems,3 resulting in weak poli- cies to mitigate children’s street involvement. In developed
regions, child protection systems may be better equipped and able to respond to street youth with policies, legislation, and programs coordinated by government and nongovernmental agencies; yet despite this, children and youth in developed re- gions continue to find themselves in street circumstances.
Globally, street-connected children and youth have signifi- cant morbidity and mortality.8-12 To develop effective evidenced- based international and national policies aimed at preventing and mitigating the harms associated with street involvement, upholding children’s rights, and ameliorating the circum- stances of the world’s most vulnerable children and youth, it is crucial to have rigorous evidence to comprehend this phenom- enon. This review aims to systematically analyze the self- reported reasons why children and youth around the world be- come street-involved and to analyze the available data by level of human development, geographic region, and sex.
Methods Operational Definitions Street-Connected Children and Youth For the purposes of this review, the term street-connected chil- dren and youth refers to any child (<1-18 years of age) or youth (15-24 years of age) who spends a portion or majority of his or her time on the streets living or working. Children and youth may have been defined as any of the following in the litera- ture: children of the street, children on the street, children from street families, homeless youth, runaway youth, throwaway youth, or working children. In the broadest sense, we in- cluded any study that referred to a child or youth who had con- nections to the streets and for whom the street played a sig- nificant role in his or her life.
Developed and Developing Regions We used the United Nations Development Programme 2013 Hu- man Development Index for categorizing studies into devel- oping vs developed regions. The Human Development Index uses a combination of indicators to measure development and categorizes countries into very high, high, medium, and low development countries.13 We defined developing countries as all those in the high, medium, and low development catego- ries and developed countries as those in the top quartile and
Key Points Question What are the self-reported reasons why children and youth around the world become street-involved?
Findings This meta-analysis compiled data from 49 studies representing 24 countries. Street-connected children and youth most frequently reported poverty, family conflict, and abuse as their reasons for street involvement and infrequently identified delinquent behaviors as a reason for their circumstances.
Meaning Children and youth’s self-reported reasons for street involvement indicate that they are in extremely difficult circumstances and require support, protection, and policies to mitigate their street involvement.
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classified as very high in the United Nations Development Pro- gramme 2013 Human Development Index Report.13
Search Strategy and Study Selection We searched for any published peer-reviewed study from 1990 through July 2013 that reported quantitative reasons for street involvement. Studies were included if they met the following inclusion criteria: (1) participants were 24 years of age or younger, (2) participants met our definition of street-connected chil- dren and youth, and (3) quantitative reasons for street involve- ment were reported. We included the following study designs: cross-sectional, cohort, case-control, mixed-methods, qualita- tive studies reporting quantitative reasons, and interventions that provided baseline data on reasons for street involvement. We excluded publications that were not written in English or that were dissertations, books, and conference abstracts.
Electronic searches of Scopus, PsychINFO, EMBASE, POPLINE, PubMed, ERIC, and the Social Sciences Citation In- dex were conducted from January 1, 1990, to the third week of July 2013. The following broad search strategy was used to search the databases: “street children” OR “street youth” OR “homeless youth” OR “homeless children” OR “runaway chil- dren” OR “runaway youth” or “homeless persons.”
After duplicates were removed, 2 independent reviewers (L.E. and J.G.) screened the titles and abstracts and excluded all records that did not meet the inclusion criteria. If either of the reviewers found an article to be relevant, a full-text copy of the article was obtained, and its eligibility assessed inde- pendently. Disagreements were resolved by discussion be- tween the 2 reviewers, and a third reviewer assisted when con- sensus could not be reached. A final list of studies to be included in this systematic review was agreed on, and the data were ex- tracted. The authors included data from their own unpub- lished work that was under review at the time of their search.14
Reference lists of selected articles were scanned to identify ad- ditional relevant documents.
Study Quality Theassessmentofmethodologicalqualitywasusedtodetermine whether the studies adequately reported study components es- sential to any study design. A critical appraisal tool was adapted to assess 10 items that should be reported to effectively assess the validity of a study’s findings.15 Details of the study quality assessment tool and the results of assessing study quality are available in the eAppendix and eTable 1 in the Supplement. The qualityassessmentwasperformedindependentlybyL.E.andJ.G. Afterward, the 2 sets of results were compared, and any disagree- ments were discussed until a consensus was reached.
Data Extraction Data were extracted by 2 independent reviewers (L.E. and J.G.) and included details about the study’s design, setting, population demographics, and results for all reported rea- sons for street involvement. When more than 1 study reported on the same sample population,16-24 the source containing the most detailed data about the reasons for street involvement was selected for the review.17,19,21,24 Data extraction was performed independently by L.E. and J.G.,
and then the results were compared. Any disagreements were discussed until a consensus was reached. When it was not possible to extract the data from the publication, we contacted the authors to ask for clarification.
Reasons and Variables Extracted data on reasons were sorted and compiled into cat- egories. The review team agreed on 6 categories that best rep- resented the themes that emerged: poverty, abuse, family con- flict, delinquency, psychosocial health, and other reasons. When studies reported multiple reasons per category, we used the most frequent response in the meta-analysis. Poverty consisted of the following variables: poverty, hunger, work to get money, hous- ing instability, rural to urban migration, structural, and refugee/ conflict/war displacement. Abuse consisted of the following vari- ables as reported in the studies: physical abuse, sexual abuse, and abuse/maltreatment and neglect. Family conflict con- sisted of the following variables: family conflict, escape home problems, abandoned, family issues, domestic violence, or- phaned, substance use at home, alcoholism at home, thrown out, mutual decision with parents, and brought to the streets by family/relative. Delinquency consisted of the following vari- ables: delinquency, conflict with the law, and removed by au- thorities. Psychosocial health consisted of the following vari- ables: sexuality/gender issues, mental health, anxiety/ depression, conflict with friends, traumatic events, personal drug and alcohol use, pregnancy, and peer pressure. Other rea- sons consisted of the following variables: runaway, desire to go to the city, independence, no clear reason, and other.
Analysis We considered a binary response (yes/no) for each reason for street involvement to estimate pooled prevalence and to as- sess effect of covariates, while accounting for individual study variations by introducing random intercepts. First, we fit lo- gistic mixed-effects models to estimate the pooled preva- lence (ie, pooled mean proportion) of each reason, and to es- timate subgroup pooled prevalence by development level or geographic region. Separate models were fit for each reason using only studies that examined the reason as a source of street involvement. To evaluate sex difference, we first created the number of female and male youth who reported yes/no to each reason from a study, and reshaped the data into a long format where each sex-yes/no datum is in a separate observation. For example, individual study data were separated into 4 obser- vations with a variable (say, num) representing number of male- poverty yes, male-poverty no, female-poverty yes, and female- poverty no. Interactions between sex and the other covariates, such as development level or geographic region, were gener- ated to estimate the subgroup pooled prevalence of each rea- son and to assess sex difference within a specific covariate level (eg, sex difference among developing countries). Because some studies reported only male data (ie, zero cells for female-yes and female-no categories), we used weighted logistic mixed models using the “num” variable as a frequency weight to avoid removing those studies from analysis. The Wald test was used throughout to assess the effect of covariate(s) and to calcu- late corresponding P values. We conducted a sensitivity analy-
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sis to drop outliers identified from diagnostic tests (available in metafor package in R version 3.0.2) and through visual in- spection of forest plots.
Results Our search identified 14 782 titles and abstracts for review af- ter removing duplicates, theses, and books. After screening, we reviewed 318 full texts and identified 64 eligible studies, of which 49 contained reasons for street involvement that could be extracted (eFigure 1 in the Supplement). In total, there were 13 559 participants from 24 countries. Of these, there were 31 studies conducted in 21 developing countries (16 low devel- opment, 10 medium development, and 5 high development
countries), with 9060 participants. The majority of these stud- ies were conducted in Africa (55%) and Asia (29%). Eighteen studies represented 3 developed countries and 4499 partici- pants (Table 1). In developing regions, 57% of participants were male and 12% were female, with 31% of unknown sex due to nonreporting. In contrast, 52% of participants were male and 48% were female in developed countries.
Table 2 and the Figure show the overall and development- level–specific pooled-prevalence estimates for each reason cat- egory. Detailed forest plots and pooled-prevalence estimates for each category of reason stratified by level of development are provided in eFigures 2 to 13 in the Supplement. Globally, the most commonly reported reason for street involvement was pov- erty, with a pooled prevalence of 39% (95% CI, 29%-51%), followed by family conflict, abuse, other, psychosocial health,
Table 1. Characteristics of the 49 Studies Included in the Review
Region and Study Country HDI Categorya Participants, Total No.
Participants, No. (%)
Age, yFemale Male Africa
Sorber et al,14 2014 Kenya Low 200 81 (41) 119 (59) 12-21
Strobbe et al,25 2013 Zambia Low 102 0 (0) 102 (100) 12-18
Ward and Seager,26 2010 South Africa Medium 305 21 (7) 284 (93) 12-17
Tadele,27 2009 Ethiopia Low 126 0 (0) 126 (100) 9-18
Plummer et al,28 2007 Sudan Low 1649 227 (14) 1422 (86) 7 to >19
Young,29 2004 Uganda Low 273 NR NR 8-17
Motala and Smith,30 2003 South Africa Medium 16 6 (38) 10 (62) 11-19
Veale and Donà,31 2003 Rwanda Low 290 26 (9) 264 (91) 14.2b
Lockhart,32 2002 Tanzania Low 75 0 (0) 75 (100) 8-20
Salem and Abd el-Latif,33 2002 Egypt Medium 100 0 (0) 100 (100) 7-16
Tchombe et al,34 2001 Cameroon Low 275 NR NR 11-18
Abdella et al,35 2000 Ethiopia Low 70 NR NR 10-16
Aderinto,36 2000c Nigeria Low 202 17 (8) 185 (92) <10-18
Lalor,37 1999 Ethiopia Low 929 NR NR NR
Lugalla and Mbwambo,38 1999 Tanzania Low 200 30 (15) 170 (85) 8-16
Matchinda,39 1999 Cameroon Low 210 NR NR NR
Anarfil,40 1997 Ghana Medium 1147 459 (40) 688 (60) <10-19
Asia
Senaratna et al,41 2013 Sri Lanka High 283 73 (26) 210 (74) 8-18
Bhat et al,42 2012 India Medium 119 0 (0) 119 (100) 11-18
Gupta,43 2012 India Medium 100 16 (16) 84 (84) 5-16
Sherman et al,44 2005 Pakistan Low 347 14 (4) 333 (96) 13d
Ali et al,45 2004 Pakistan Low 108 21 (19) 87 (81) 8-12
Tiwari et al,46 2002 India Medium 400 0 (0) 400 (100) 6-16
Senanayake et al,47 1998 Sri Lanka High 50 18 (36) 32 (64) 4-17
Baker et al,24 1997 Nepal Low 130 0 (0) 130 (100) 6-17
Patel,48 1990 India Medium 1000 NR NR NR
South America
Huang et al,49 2004 Bolivia Medium 124 39 (31) 85 (69) 3-18
Lee and Odie-Ali,50 2000 Guyana Medium 25 0 (0) 25 (100) 9-17
Raffaelli et al,51 2000 Brazil High 66 33 (50) 33 (50) 10-18
Aneci Rosa et al,52 1992 Brazil High 80 0 (0) 80 9-18
Eurasia
Murray et al,53 2012 Georgia High 59 NR NR NR
Subtotal
31 Studies 21 Countries Low = 16, medium = 10, high = 5
9060 1081 (12)e 5163 (57)e 3-21
(continued)
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and, lastly, delinquency. Of the 49 studies included in this re- view, 47 (96%) reported family conflict–related reasons for street involvement, with a pooled-prevalence estimate of 32% (95% CI, 26%-39%). Abuse was almost equally reported in develop- ing and developed countries, with an overall pooled preva- lence of 26% (95% CI, 18%-35%). Other reasons had an overall pooled prevalence of 20% (95% CI, 13%-29%). Within the other category, “running away” was the most frequently reported rea- son in North America (38%), and “independence” was the most frequently reported reason in the Pacific, representing the de- veloped world; a “desire to go the city” (10%) and “other gen- eral reasons” (12%) were the most frequently reported reasons in the developing regions. Psychosocial-related reasons had a pooled-prevalence estimate of 16% (95% CI, 11%-23%). Lastly, delinquency was the least frequently cited reason overall, with a pooled prevalence of 10% (95% CI, 5%-20%).
Street involvement due to poverty-related reasons was reported in all 31 studies representing developing regions and was the most frequently reported factor with a pooled- prevalence estimate of 41% (95% CI, 30%-53%). Similar pooled- prevalence estimates for abuse- and family conflict–related rea- sons were reported at 24% (95% CI, 16%-35%) and 24% (95% CI, 18%-31%), respectively, in the developing regions.
In developed countries, family conflict was the most fre- quently reported reason for street involvement with a pooled- prevalence estimate of 48% (95% CI, 38%-58%), with all the studies from developed regions contributing to this estimate. Similar pooled-prevalence estimates for abuse (29% [95% CI, 15%-48%]) and psychosocial health (26% [95% CI, 19%-35%]) were reported in developed countries.
Tests for differences between developing and developed re- gion subgroups resulted in significant differences in all re- ported reasons for street involvement with the exception of pov- erty and abuse. We conducted a sensitivity analysis (eTable 2 and eFigures 14-17 in the Supplement) to exclude outliers iden- tified in diagnostic tests and through visual inspection of for- est plots, but no significant difference was observed for poverty- related reasons between developed and developing countries.
Table 3 demonstrates the most frequently reported reasons for street involvement by geographic region. Detailed forest plots and pooled-prevalence estimates for each category of reason stratified by geographic region are provided in eFigures 18 to 23 in the Supplement. Poverty-related reasons for street involve- mentweremostcommonlyreportedinAfrica(49%[95%CI,34%- 65%]), Asia (28% [95% CI, 18%-41%]), Eurasia (83% [95% CI, 71%- 91%]), and South and Central America (27% [95% CI, 5%-71%]).
Table 1. Characteristics of the 49 Studies Included in the Review (continued)
Region and Study Country HDI Categorya Participants, Total No.
Participants, No. (%)
Age, yFemale Male North America
Mayfield Arnold et al,54 2012 United States Very high 73 38 (52) 35 (48) 16-20
Coates and McKenzie-Mohr,55 2010 Canada Very high 102 36 (35) 66 (65) 16-24
Peressini,56 2007 Canada Very high 86 29 (34) 57 (66) ≤24
Hyde,57 2005 United States Very high 50 25 (50) 25 (50) 18-23
Safyer et al,58 2004 United States Very high 61 37 (61) 24 (39) 15.9b
Rew et al,17 2002 United States Very high 414 170 (41) 244 (59) 16-20
Moon et al,59 2001 United States Very high 204f 95 (47) 108 (53) 14-21
Cauce et al,21 2000 United States Very high 364 153 (42) 211 (58) 13-21
Ennett et al,60 1999 United States Very high 288 148 (51) 140 (49) 14-21
Nadon et al,61 1998 Canada Very high 79 79 (100) 0 (0) 13-18
Ringwalt et al,62 1998 United States Very high 1159 591 (51) 568 (49) 12-21
Boesky et al,63 1997 United States Very high 122 83 (68) 39 (32) 12-17
Booth and Zhang,64 1996 United States Very high 219 101 (46) 118 (54) 12-19
Janus et al,65 1995 Canada Very high 187 74 (40) 113 (60) 16-21
Whitbeck and Simons,66 1993 United States Very high 156 73 (47) 83 (53) 14-18
Oceania
Rosenthal et al,19 2006 Australia Very high 692 349 (50) 343 (50) 12-20
Howard,67 1993 Australia Very high 192 56 (29) 136 (71) 13-20
Hier et al,68 1990 Australia Very high 52 26 (50) 26 (50) NR
Subtotal
18 Studies 3 Countries Very high 4499 2162 (48) 2337 (52) 12 to ≤24
Total
49 Studies 24 Countries Developed = 18, developing = 31
13559 3243 (24)g 7500 (55)g 3 to ≤24
Abbreviations: HDI, Human Development Index; NR, not reported. a Based on the 2013 Human Development Report. b Mean age. c Excluding nonstreet children. d Median age.
e Thirty-one percent of sex data were not reported. f One person was transgender, so the male and female columns do not equal
study total. g Twenty-one percent of sex data were not reported.
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Family conflict was the primary reason in North America (47% [95% CI, 36%-58%]) and the Pacific region (54% [95% CI, 30%- 76%]). Tests for differences between geographic regions resulted in significant differences for family conflict, delinquency, and otherreasons.Familyconflictwasdifferentbygeographicregions
(P = .02). eFigure 24 in the Supplement shows the pooled- prevalence estimates for reported reasons of street involvement grouped by geographic region. We conducted a sensitivity analy- sis comparing reasons for street involvement by geographic re- gion when removing outliers identified by diagnostic tests and
Table 2. Overall and Development-Level–Specific Pooled-Prevalence Estimates Comparing Reasons for Street Involvement
Reason No. of Studies
No. of Street-Involved Participants Who Reported Reason
Total No. of Participants
Pooled-Prevalence Estimates, % (95% CI) P Valuea
Poverty 35 5047 11 285 39 (29-51)
.51Developing 31 4810 9060 41 (30-53)
Developed 4 496 2225 30 (8-67)
Abuse 28 2172 8675 26 (18-35)
.64Developing 19 950 5577 24 (16-35)
Developed 16 1223 3098 29 (15-48)
Family conflict 47 4685 13 435 32 (26-39)
<.001Developing 29 2301 8936 24 (18-31)
Developed 18 2384 4499 48 (38-58)
Delinquency 7 493 3159 10 (5-20)
<.001Developing 3 28 788 3 (2-8)
Developed 4 465 2371 20 (18-21)
Psychosocial 21 1790 7070 16 (11-23)
.03Developing 13 1189 5346 12 (7-20)
Developed 8 601 1724 26 (19-35)
Other 34 2500 10 425 20 (13-29)
.001Developing 21 1324 7939 11 (7-15)
Developed 13 1176 2486 46 (30-63) a Wald test for differences in
development level.
Figure. Overall and Development-Level–Specific Forest Plot of Pooled-Prevalence Estimates and 95% CIs for Reasons for Street Involvement
Prevalence (95% CI) 0 0.30 0.800.20 0.700.600.500.400.10
Total No. No. of Events
Poverty
Prevalence (95% CI)
11 285 5047Overall 0.39 (0.29-0.51) 9060 4810Developing 0.41 (0.30-0.53) 2225 496Developed 0.30 (0.08-0.67)
Abuse 8675 2172Overall 0.26 (0.18-0.35) 5577 950Developing 0.24 (0.16-0.35) 3098 1223Developed 0.29 (0.15-0.48)
Family conflict 13 435 4685Overall 0.32 (0.26-0.39)
8936 2301Developing 0.24 (0.18-0.31) 4499 2384Developed 0.48 (0.38-0.58)
Delinquency 3159 493Overall 0.10 (0.05-0.20)
788 28Developing 0.03 (0.02-0.08) 2371 465Developed 0.20 (0.18-0.21)
Psychosocial 7070 1790Overall 0.16 (0.11-0.23) 5346 1189Developing 0.12 (0.07-0.20) 1724 601Developed 0.26 (0.19-0.35)
Other 10 425 2500Overall 0.20 (0.13-0.29)
7939 1324Developing 0.11 (0.07-0.15) 2486 1176Developed 0.46 (0.30-0.63)
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visual inspection (eTable 3 and eFigures 25-26 in the Supple- ment). This resulted in no changes to significant differences by different regions at a significance level of .05. However, the re- sults indicated that poverty reported in Peressini56 might devi- ate from other North American studies.
Finally, we examined sex differences for stated reasons within developing and developed regions when the data were reported (eTable 4 in the Supplement). We found no signifi- cant differences in the reasons male and female participants reported for their street involvement, with the exception of abuse in developed regions. Female participants in devel- oped regions more frequently reported abuse-related reasons
for street involvement (28% [95% CI, 14%-49%]) than male par- ticipants (18% [95% CI, 8%-37%]) (P = .01). In contrast, in de- veloping countries, male participants were more likely to re- port abuse as a primary reason for being street connected (22%) compared with female participants (13%), although it failed to reach statistical significance.
Discussion This review shows that the leading cause of street involvement as self-reported by children and youth worldwide is related to
Table 3. Pooled-Prevalence Estimates Comparing Reasons for Street Involvement by Geographic Regions
Reason and Region No. of Studies
No. of Street-Involved Participants Who Reported Reason
Total No. of Participants
Pooled Prevalence, % (95% CI) P Valuea
Poverty 35 5047 11 285 39 (29-51)
.16
Africa 17 3770 6169 49 (34-65)
Asia 9 644 2537 28 (18-41)
Eurasia 1 49 59 83 (71-91)
North America 3 360 1533 34 (6-81)
Pacific 1 136 692 20 (17-23)
South and Central America 4 88 295 27 (5-71)
Abuse 28 2172 8675 26 (18-35)
.98
Africa 11 687 4462 25 (12-44)
Asia 4 176 841 18 (10-32)
Eurasia 1 18 59 31 (20-43)
North America 8 1055 2406 29 (14-51)
Pacific 1 167 692 24 (21-27)
South and Central America 3 69 215 31 (21-43)
Family conflict 47 4685 13 435 32 (26-39)
.02
Africa 16 1510 6153 25 (16-36)
Asia 8 710 2429 23 (13-38)
Eurasia 1 59 22 37 (26-50)
North America 15 1786 3563 47 (36-58)
Pacific 3 598 936 54 (30-76)
South and Central America 4 59 295 18 (7-37)
Delinquency 7 493 3159 10 (5-20)
<.001
Africa 3 28 788 7 (4-12)
Asia 0 0 0
Eurasia 0 0 0
North America 3 335 1679 20 (18-22)
Pacific 1 130 692 19 (16-22)
South and Central America 0 0 0
Psychosocial 21 1775 6870 16 (11-23)
.27
Africa 11 1097 4287 12 (6-22)
Asia 1 83 1000 8 (7-10)
Eurasia 1 9 59 15 (8-27)
North America 6 220 840 23 (16-31)
Pacific 2 381 884 37 (19-59)
South and Central America 0 0 0
Other 34 2500 10 425 20 (13-29)
.06
Africa 11 952 5578 8 (4-14)
Asia 6 331 2032 17 (12-24)
Eurasia 1 6 59 10 (5-21)
North America 11 830 1742 45 (27-65)
Pacific 2 346 744 47 (43-50)
South and Central America 3 35 270 13 (5-29) a Wald test for differences in
geographic region.
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variables categorized as poverty, and when stratified by devel- opment level, this remains true in developing countries, whereas family conflict–related reasons are most commonly reported in developed countries. It is likely that more than 1 factor contrib- utes to children and youth’s street involvement and that the rea- sons may interact synergistically. Nonetheless, with poverty, family conflict, and abuse being the most commonly reported reasons for street involvement across levels of development, it isapparentthatchildrenandyouthwhohaveturnedtothestreets are doing so as a means of survival due to unfavorable conditions within their homes and that they are not typically delinquents (as they are so often perceived).1,3,6,7 These results have strong implications for policy internationally; demonstrating that crimi- nalization and policies that place street-connected children and youth in detention centers are likely to be ineffective strategies that violate their human rights instead of providing protection.
Globally, street-connected children and youth have significant morbidity8,69 and mortality10 and are at high risk of substance use,9 sexual exploitation,12 and the human immunodeficiency virus.70,71 There is a dearth of evaluated in- terventions for street-connected children and youth, particu- larly in low- and middle-income countries.72 To prevent and reduce these high rates of morbidity and mortality and high number of rights violations, strategies are urgently needed to mitigate street involvement, and interventions are required to respond to those already on the street.
There is a clear need to develop and strengthen social pro- tection policies and child welfare systems in both developing and developed countries to address poverty, abuse, and family con- flict impacting children’s street involvement. Poverty reduction strategies,suchascash-transferprograms,feedingprograms,and universal free primary and secondary education, aimed at sup- porting vulnerable households and increasing human capital, may greatly reduce children’s street involvement. Social cash transfers have had positive effects on children’s well-being in many settings73 and may affect child protection outcomes, in- cluding reducing the probability of abuse, exploitation, and vio- lence against children through direct or indirect effects.74 Ex- panding and augmenting social protection programs are likely tosignificantlyreducestreetinvolvementinassociationwithpov- erty reduction and child protection.
In low- and middle-income countries with weak or nonex- istent child protection systems, policies should be designed, implemented, and enforced to protect children and youth in situ- ationsofabuseandfamilyconflict. Indevelopedregions,thechild welfaresystemmaynotbeadequatelyprotectingvulnerablechil- dren and youth. Family breakdown, maltreatment, and conflict often lead to homelessness18 and involvement in the foster care system. There is a clear relationship between a youth’s homeless- ness and his or her involvement in the foster care system, and there is hope for improving the safety net for vulnerable youth in developed regions.75
This review has several strengths and limitations. To the best of our knowledge, this is the first study to compile data and present pooled estimates concerning reported reasons for street involvement. It includes studies across 24 countries compar- ing results by level of development and sex, making it gener- alizable to street children and youth globally. This review only
included English language peer-reviewed studies, which may have resulted in the exclusion of studies published in other lan- guages and may reflect the lack of studies from Europe and South and Central America, limiting generalizability to these regions. Second, not all studies measured or reported the same reasons, and we compiled reported reasons into categories re- flecting their general theme; this may have resulted in some mis- classification bias. We attempted to limit bias by independently extracting and comparing data, and reviewing final categori- zation as a team. Third, we did not include gray literature and, therefore, may have missed reported reasons in reports. Fourth, self-reported reasons for street involvement are subject to re- porting and social desirability bias, which may not accurately reflect the reasons for street involvement. Fifth, the “other” category should be interpreted with caution owing to the group- ing of data. Studies in the “other” category that reported rea- sons as “runaway,” “other,” or “no clear reason” may not rep- resent the underlying reason that the child or youth left home and, therefore, should be interpreted with caution. Sixth, our assessment of outliers with diagnostic tests may not have been sufficiently powered, and our assessment based on visual in- spection may be inaccurate; therefore, the sensitivity analyses should be interpreted with caution. Seventh, we were unable to analyze reasons by age owing to a lack of data stratified by age. It is possible that self-reported reasons vary by age and the age they first came to the streets, which would have important policy implications. Lastly, there was a disparity in the inclu- sion of girls in developing regions compared with developed re- gions, which may have impacted the analysis of sex. Data were not always reported stratified by sex, and there were a large pro- portion of study participants not classified as either male or fe- male in developing country studies. This points to a need to en- sure research reaches girls on the street because they are an especially vulnerable and hard-to-reach population.
Conclusions Preventing street involvement and mitigating its harms are critical to helping children and youth achieve their potential. There is an urgent need for international collaborations among researchers, policy makers, stakeholders, and organizations working with street-connected children and youth to formu- late strategies to prevent them from turning to the streets and assist those already involved in street life. The street- connected children and youth who provided reasons for their street involvement infrequently identified delinquent behav- iors for their circumstances and highlighted the role of pov- erty as a driving factor for their street involvement. With the global refugee crisis, it will be important to monitor changes in the number of children taking to the streets as a result of displacement and conflict. The self-reported reasons that were given indicate that these children and youth are in extremely difficult circumstances and are subject to numerous human rights violations. They require support and protection, and gov- ernments globally are called on to reduce the socioeconomic inequities that cause children and youth to turn to the streets in the first place, in all regions of the world.
Research Original Investigation Causes of Child and Youth Homelessness
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ARTICLE INFORMATION
Accepted for Publication: January 17, 2016.
Published Online: April 4, 2016. doi:10.1001/jamapediatrics.2016.0156.
Author Affiliations: Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada (Embleton); Department of Biostatistics, Brown University, Providence, Rhode Island (Lee); Division of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (Gunn); Department of Behavioral Sciences, College of Health Sciences, Moi University, Eldoret, Kenya (Ayuku); Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (Braitstein); Department of Medicine, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya (Braitstein); Department of Epidemiology, Fairbanks School of Public Health, Indiana University, Indianapolis (Braitstein); Regenstrief Institute Inc, Indianapolis, Indiana (Braitstein).
Author Contributions: Dr Braitstein and Ms Embleton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Embleton, Gunn, Ayuku, Braitstein. Acquisition, analysis, or interpretation of data: Embleton, Lee, Gunn. Drafting of the manuscript: Embleton, Lee, Gunn, Braitstein. Critical revision of the manuscript for important intellectual content: Embleton, Ayuku. Statistical analysis: Embleton, Lee. Obtained funding: Ayuku. Administrative, technical, or material support: Embleton, Gunn, Braitstein. Study supervision: Embleton, Ayuku.
Conflict of Interest Disclosures: None reported.
Funding/Support: This project was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R01HD060478). This work was also supported by the Canadian Institutes of Health Research through an Applied Public Health Chair award to Dr Braitstein.
Role of the Funder/Sponsor: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Canadian Institutes of Health Research had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health, or the Canadian Institutes of Health Research.
Additional Contributions: We thank Beth Rachlis, PhD, at the Ontario HIV Treatment Network, Toronto, Canada, for assisting in data extraction and quality assessment as a third reviewer, Samuel Ayaya, MBChB, MMed, at the Department of Child Health and Paediatrics, Moi University, College of Health Sciences, Eldoret, Kenya, for his review of the manuscript, and Thomas Trikalinos, PhD, at the
Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, for his expert advice. No compensation was received from a funding sponsor for such contributions.
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