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The Health Status of Street Children and Youth in Low- and Middle-Income Countries: A Systematic Review of the Literature

  • Jessica Woan
    Affiliations
    University of Washington School of Medicine, Seattle, Washington
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  • Jessica Lin
    Affiliations
    Division of Adolescent Medicine, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California
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  • Colette Auerswald
    Correspondence
    Address correspondence to: Colette Auerswald, M.D., M.S., Associate Professor of Pediatrics, Division of Adolescent Medicine, UCSF, Associate Professor and Director of MS Program, UC Berkeley-UCSF Joint Medical Program, UC Berkeley School of Public Health, c/o JMP, 570-R University Hall MC #1190, Berkeley, CA 94720-1190.
    Affiliations
    Division of Adolescent Medicine, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California

    University of California, Berkeley-University of California at San Francisco Joint Medical Program, UC Berkeley School of Public Health, Berkeley, California
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      Abstract

      The health of the tens of millions of street children globally is understudied. We undertook a systematic review of the existing quantitative literature regarding the health status of street children and youth in low- and middle-income countries to summarize available knowledge, identify underexplored areas of research, and inform the future research agenda regarding the health of this population. A total of 108 articles met our inclusion criteria. Demographic data and structural factors associated with street life are summarized. Although data in specific regions or diseases are sparse, the literature review illustrates that youth's survival behaviors and the exposures associated with poor shelter have resulted in disproportionate morbidity in the areas of infectious illness, psychiatric disease, reproductive health, and perhaps to a lesser extent, growth. Vast areas of health that may disproportionately affect street children in childhood or later on as adults have not been investigated, including chronic diseases and cognitive deficits. Studies of specific diseases or conditions vary considerably by region. Strengths and limitations of the literature are discussed and principles for future research in this area are proposed.

      Keywords

      Implications and Contribution
      Our literature review systematically documents areas of street child health that are understudied or not studied at all as well as the limitations of current research. Informed by our findings, our principles for further research can inform the future study of this vulnerable population.
      A street child, as defined by UNICEF, is one “for whom the street (in the widest sense of the word, i.e., unoccupied dwellings, wasteland, etc.) more than their family has become their real home, a situation in which there is no protection, supervision, or direction from responsible adults” [

      UNICEF Executive Board. Exploitation of working children and street children. U.N. Doc. E/ICEF/1986/CRP.1983; 1986.

      ]. Although the number of children and youth who live on the streets of the world's cities is unknown, existing estimates suggest that tens of millions of children are street-based and that their numbers are rising secondary to global population growth, the HIV epidemic, migration, and increasing urbanization [

      UNICEF. The state of the world's children 2012: Excluded and invisible: United Nations Publications Report No.: 9280639161; 2012.

      ]. The vast majority of the world's children, and of the world's street children, live in low- and middle-income countries [

      World Bank. How we classify countries. 2012. Available at: http://data.worldbank.org/about/country-classifications (accessed April 5, 2013).

      ], yet existing research regarding street children and youth has overwhelmingly been conducted in high-income countries.
      UNICEF defines two overlapping groups of street children: on-the-street children, who are street-based but primarily sleep at home, and of-the-street children, who rarely, if ever, return home. There is general agreement in the literature that most street children are on-the-street rather than of-the-street [
      • Hutz C.S.
      • Koller S.H.
      Methodological and ethical issues in research with street children.
      ,
      • Raffaelli M.
      • Koller S.H.
      • Reppold C.T.
      • et al.
      Gender differences in Brazilian street youth's family circumstances and experiences on the street.
      ,
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      ,
      • Jones G.A.
      • Herrera E.
      • Thomas de Benítez S.
      Tears, trauma and suicide: Everyday violence among street youth in Puebla, Mexico.
      ]. Though these terms have been widely and appropriately critiqued, they remain the most currently used and provide an important distinction. As has been well documented, disconnection from family, community, and social capital is associated with poorer health outcomes [
      • Berkman L.F.
      • Kawachi I.
      Social epidemiology.
      ,
      • Kawachi I.
      • Subramanian S.
      • Kim D.
      Social capital and health.
      ,
      • Sawyer S.M.
      • Afifi R.A.
      • Bearinger L.H.
      • et al.
      Adolescence: A foundation for future health.
      ,

      World Health Organization. Programming for adolescent health and development. WHO technical report series no. 886. Report of WHO/UNFPA/UNICEF Study Group on Programmin1g for Adolescent Health; 1999.

      ]. Thus, an of-the-street child may experience substantively different challenges and health outcomes than his or her on-the-street counterpart. There is a longstanding history of qualitative research regarding the survival strategies and lived experience of street children. However, quantitative research regarding the health status of both of- and on-the-street children in low- and middle-income countries is limited.
      As emphasized in recent reviews of adolescent health, adolescence is a critical period of development, during which many of the health-related behaviors that will affect young people both in the present and into adulthood are initiated. Investment in adolescent health has lasting impacts on a country's overall health and economic wellbeing [
      • Viner R.M.
      • Ozer E.M.
      • Denny S.
      • et al.
      Adolescence and the social determinants of health.
      ]. The goal of this review is to summarize available knowledge and identify underexplored areas of the health of street children in order to encourage and inform interventions and the future research agenda regarding street children in resource-limited settings. Our approach was informed by an ecological framework, consistent with the World Health Organization's definition of health as “a state of complete physical, mental, and social well-being” [
      • World Health Organization
      Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946, and entered into force on 7 April 1948.
      ]. Our review therefore included studies that examined a range of health outcomes among street children, including both traditional health indicators such as nutritional and growth status, and globally recognized, broader determinants of adolescent health, such as experiences of violence, substance use, and mental health [

      UNICEF. The state of the world's children 2011: Adolescence—An Age of Opportunity 2011. Available at: http://www.unicef.org/publications/index_57468.html. Accessed April 5, 2013.

      ].

      Methods

      Figure 1 summarizes our literature search. We performed a systematic search of 18 databases for articles published between January 1995 and September 2011 using the key words homeless youth and street youth. We complemented our formal search with reports from the gray literature (i.e., non–peer-reviewed reports from nongovernmental organizations or national or international bodies) found online or referenced in other sources. A few frequently cited studies coincident with the escalating HIV epidemic and published in 1994 were also included. A total of 7,348 citations were found in the database searches and gray literature and reviewed for inclusion.
      Inclusion criteria included: quantitative measures of the health of street children and youth up to 24 years of age; publication in an English, French, or Spanish language journal; publication between January 1, 1995, and September 1, 2011; and research conducted in low- and middle-income countries (Figure 1), as defined by the World Bank's 2009 classifications according to gross national income per capita [
      World Bank income classifications July 2009.
      ]. Though a wide range of wealth is included in this list, many of the upper-middle income countries included underwent dramatic economic change over the time period covered in the review.
      Studies were excluded if they: were exclusively qualitative, examined youth living within homeless or refugee families, included homeless youth within a broader population without providing age-specific data, or did not provide original data.
      A total of 108 articles representing 35 countries met inclusion criteria and were included in this review. The most studied health outcomes (detailed in Table 1, Table 2, Table 3, which can be found in the online edition of this article) were nutritional status, substance use, and sexual health.
      Definitions and eligibility criteria employed by investigators, generally study-specific, often differ from each other and from those employed by the United Nations. To standardize our review, we translated, when analogous, the varying terms used by researchers into of-the-street and on-the-street. Otherwise, study participants are referred to simply as street children.

      Results

      Demographics

      Children reported leaving home when they were between 6 and 16 years of age and having lived on the streets for a period of days to, more frequently, years [
      • Nada K.H.
      • Suliman E.D.A.
      Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.
      ,

      Ramakrishna J, Karott M, Murthy R. Experiences of sexual coercion among street boys in Bangalore, India. In: Bott S, Jejeebhoy S, Shah I, et al, eds. Towards adulthood: Exploring the sexual and reproductive health of adolescents in South Asia. Geneva, Switzerland: 2003. p. 95–98.

      ,
      • Agnihotri P.
      Street boys of Delhi: A study of their family and demographic characteristics.
      ,
      • Ali A.
      • de Muynck A.
      Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan - a qualitative study.
      ,
      • Sherman S.S.
      • Plitt S.
      • ul Hassan S.
      • et al.
      Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan.
      ,
      • Beyene Y.
      • Berhane Y.
      Characteristics of street children in Nazareth, Ethiopia.
      ,
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      • Nzimakwe D.
      • Brookes H.
      An investigation to determine the health status of institutionalised street children in a place of safety in Durban.
      ,
      • Raffaelli M.
      • Koller S.H.
      • Morais D.
      • et al.
      Assessing the development of Brazilian street youth.
      ,
      • Ruiz J.
      Street youth in Colombia: Lifestyle, attitudes and knowledge. AIDS health promotion exchange/World Health Organization, Global Programme on AIDS.
      ,
      • Wutoh A.K.
      • Kumoji E.K.
      • Xue Z.Y.
      • et al.
      HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana.
      ,
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      ,
      • Matchinda B.
      The impact of home background on the decision of children to run away: The case of Yaounde city street children in Cameroon.
      ,
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      ,
      • Panter-Brick C.
      • Todd A.
      • Baker R.
      Growth status of homeless Nepali boys: Do they differ from rural and urban controls?.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Tiwari P.
      Life on streets.
      ,
      • Pagare D.
      • Meena G.
      • Singh M.
      • et al.
      Risk factors of substance use among street children from Delhi.
      ,
      • Pagare D.
      • Meena G.S.
      • Jiloha R.C.
      • et al.
      Sexual abuse of street children brought to an observation home.
      ,
      • Lugalla J.L.P.
      • Mbwambo J.K.
      Street children and street life in urban Tanzania: The culture of surviving and its implications for children's health.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      ]. On-the-street children tended to be younger than of-the-street children (10–12 vs. 13–16 years old) [
      • Ali M.
      • Shahab S.
      • Ushijima H.
      • et al.
      Street children in Pakistan: A situational analysis of social conditions and nutritional status.
      ,
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • Raffaelli M.
      • Siqueira E.
      • Paynemerritt A.
      • et al.
      HIV-related knowledge and risk behaviors of street youth in Belo-Horizonte, Brazil.
      ]. These data suggest that on-the-street children may grow to be of-the-street youth. However, longitudinal cohort data needed to support this hypothesis are absent.
      Boys were the most visible group on the street in low- and middle-income countries, constituting 50% to 100% of study samples reviewed. Where reported, of-the-street boys were often significantly older than of-the-street girls [
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • Raffaelli M.
      • Siqueira E.
      • Paynemerritt A.
      • et al.
      HIV-related knowledge and risk behaviors of street youth in Belo-Horizonte, Brazil.
      ,
      • Gurgel R.
      • Da Fonseca J.
      • Neyra-Castaneda D.
      • et al.
      Capture-recapture to estimate the number of street children in a city in Brazil.
      ,
      • Anarfi J.K.
      Vulnerability to sexually transmitted disease: Street children in Accra.
      ,
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      ,
      • Anarfi J.K.
      Street youth in Accra city: Sexual networking in a high-risk environment and its implications for the spread of HIV /AIDS.
      ]. Boys had generally spent more years on the street than girls, whereas girls tended to have more contact with family [
      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      ,
      • Kidolezi Y.N.
      • Holmes J.A.
      • Nopo H.
      • et al.
      Selection and reporting bias in household surveys of child labor: Evidence from Tanzania.
      ]. Several studies hypothesized that street girls may have experienced more severe familial breakdown, because impoverished boys are more likely to be sent to the street by families to earn money, whereas girls are generally kept at home to help with the household [
      • Raffaelli M.
      • Koller S.H.
      • Reppold C.T.
      • et al.
      Gender differences in Brazilian street youth's family circumstances and experiences on the street.
      ,
      ,
      • Aptekar L.
      • Ciano-Federoff L.M.
      Street children in Nairobi: Gender differences in mental health.
      ,
      • Abdelgalil S.
      • Gurgel R.G.
      • Theobald S.
      • et al.
      Household and family characteristics of street children in Aracaju, Brazil.
      ]. Girls may also be more amenable than boys to sleep in institutions, be living with relatives, be recruited into sex work, or be in “sugar daddy” relationships with older men, all of which may render them less visible [
      • Raffaelli M.
      • Koller S.H.
      • Reppold C.T.
      • et al.
      Gender differences in Brazilian street youth's family circumstances and experiences on the street.
      ,
      ,
      • Kidolezi Y.N.
      • Holmes J.A.
      • Nopo H.
      • et al.
      Selection and reporting bias in household surveys of child labor: Evidence from Tanzania.
      ].

      Structural factors affecting street children's health

      Children most frequently reported family conflict (including violence, parental drug use, physical abuse, neglect) or changes in family structure (death of a parent, remarriage and resulting discrimination or abandonment) as their reason for being on the street [
      • Raffaelli M.
      • Koller S.H.
      • Reppold C.T.
      • et al.
      Gender differences in Brazilian street youth's family circumstances and experiences on the street.
      ,
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ,
      • Lugalla J.L.P.
      • Mbwambo J.K.
      Street children and street life in urban Tanzania: The culture of surviving and its implications for children's health.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      ,
      • Abdelgalil S.
      • Gurgel R.G.
      • Theobald S.
      • et al.
      Household and family characteristics of street children in Aracaju, Brazil.
      ,
      • Aderinto A.A.
      Social correlates and coping measures of street-children: A comparative study of street and non-street children in south-western Nigeria.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Lee J.A.B.
      • Odie-Alie S.
      Carry me home: A collaborative study of street children in Georgetown, Guyana.
      ,
      • Lalor K.J.
      Street children: A comparative perspective.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Grundling J.
      • Grundling I.
      The concrete particulars of the everyday realities of street children.
      ,
      • Veale A.
      • Donà G.
      Street children and political violence: A socio-demographic analysis of street children in Rwanda.
      ,
      • Seager J.R.
      • Tamasane T.
      Health and well-being of the homeless in South African cities and towns.
      ]. Other reasons for leaving home included poverty, learning a trade, peer encouragement, running away from a children's institution, adventure-seeking, and escaping political violence [

      Ramakrishna J, Karott M, Murthy R. Experiences of sexual coercion among street boys in Bangalore, India. In: Bott S, Jejeebhoy S, Shah I, et al, eds. Towards adulthood: Exploring the sexual and reproductive health of adolescents in South Asia. Geneva, Switzerland: 2003. p. 95–98.

      ,
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ,
      • Lugalla J.L.P.
      • Mbwambo J.K.
      Street children and street life in urban Tanzania: The culture of surviving and its implications for children's health.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      ,
      • Ali M.
      • Shahab S.
      • Ushijima H.
      • et al.
      Street children in Pakistan: A situational analysis of social conditions and nutritional status.
      ,
      • Anarfi J.K.
      Vulnerability to sexually transmitted disease: Street children in Accra.
      ,
      • Aderinto A.A.
      Social correlates and coping measures of street-children: A comparative study of street and non-street children in south-western Nigeria.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Lalor K.J.
      Street children: A comparative perspective.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Grundling J.
      • Grundling I.
      The concrete particulars of the everyday realities of street children.
      ,
      • Veale A.
      • Donà G.
      Street children and political violence: A socio-demographic analysis of street children in Rwanda.
      ].
      Street children primarily earned money through informal economies, including working as vendors, parking attendants, street performers, garbage collectors and recyclers, shoe shiners, sex workers, or petty thieves [
      • Sherman S.S.
      • Plitt S.
      • ul Hassan S.
      • et al.
      Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan.
      ,
      • Beyene Y.
      • Berhane Y.
      Characteristics of street children in Nazareth, Ethiopia.
      ,
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      ,
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Tiwari P.
      Life on streets.
      ,
      • Lugalla J.L.P.
      • Mbwambo J.K.
      Street children and street life in urban Tanzania: The culture of surviving and its implications for children's health.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,
      • Ali M.
      • Shahab S.
      • Ushijima H.
      • et al.
      Street children in Pakistan: A situational analysis of social conditions and nutritional status.
      ,
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Anarfi J.K.
      Vulnerability to sexually transmitted disease: Street children in Accra.
      ,
      • Anarfi J.K.
      Street youth in Accra city: Sexual networking in a high-risk environment and its implications for the spread of HIV /AIDS.
      ,
      • Aderinto A.A.
      Social correlates and coping measures of street-children: A comparative study of street and non-street children in south-western Nigeria.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Grundling J.
      • Grundling I.
      The concrete particulars of the everyday realities of street children.
      ,
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      ,
      • Towe V.L.
      • ul Hasan S.
      • Zafar S.T.
      • et al.
      Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.
      ,
      • Ogel K.
      • Taner S.
      • Tosun M.
      • et al.
      Juvenile offences among hospitalized adolescent inhalant users in Istanbul: A comparison regarding place of residence.
      ,
      • Mondal N.K.
      • Ghosh S.
      • Ray M.R.
      Micronucleus formation and DNA damage in buccal epithelial cells of Indian street boys addicted to gasp ‘Golden glue’.
      ,
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      ]. Few youth reported begging as their sole source of income, though the frequency of panhandling for supplemental income varied across studies [
      • Beyene Y.
      • Berhane Y.
      Characteristics of street children in Nazareth, Ethiopia.
      ,
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Anarfi J.K.
      Street youth in Accra city: Sexual networking in a high-risk environment and its implications for the spread of HIV /AIDS.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Grundling J.
      • Grundling I.
      The concrete particulars of the everyday realities of street children.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ]. Money earned was typically sent to family or spent on food, entertainment, or drugs [
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Abdelgalil S.
      • Gurgel R.G.
      • Theobald S.
      • et al.
      Household and family characteristics of street children in Aracaju, Brazil.
      ,
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      ].
      The majority of participating street children were not currently in school [
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Wutoh A.K.
      • Kumoji E.K.
      • Xue Z.Y.
      • et al.
      HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana.
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,
      • Aderinto A.A.
      Social correlates and coping measures of street-children: A comparative study of street and non-street children in south-western Nigeria.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Ikechebelu J.I.
      • Udigwe G.O.
      • Ezechukwu C.C.
      • et al.
      Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria.
      ,
      • Baybuga M.S.
      • Celik S.S.
      The level of knowledge and views of the street children/youth about AIDS in Turkey.
      ]. Where reported, most had ceased schooling at primary levels [
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      ,
      • Agnihotri P.
      Street boys of Delhi: A study of their family and demographic characteristics.
      ,
      • Beyene Y.
      • Berhane Y.
      Characteristics of street children in Nazareth, Ethiopia.
      ,
      ,
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      ,
      • Lugalla J.L.P.
      • Mbwambo J.K.
      Street children and street life in urban Tanzania: The culture of surviving and its implications for children's health.
      ,

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • Anarfi J.K.
      Street youth in Accra city: Sexual networking in a high-risk environment and its implications for the spread of HIV /AIDS.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      ,
      • Towe V.L.
      • ul Hasan S.
      • Zafar S.T.
      • et al.
      Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.
      ,
      • Mondal N.K.
      • Ghosh S.
      • Ray M.R.
      Micronucleus formation and DNA damage in buccal epithelial cells of Indian street boys addicted to gasp ‘Golden glue’.
      ,
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      ,
      • Ikechebelu J.I.
      • Udigwe G.O.
      • Ezechukwu C.C.
      • et al.
      Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria.
      ,
      • Duyan V.
      Relationships between the sociodemographic and family characteristics, street life experiences and the hopelessness of street children.
      ,
      • D'Abreu R.C.
      • Mullis A.K.
      • Cook L.R.
      The resiliency of street children in Brazil.
      ]. When assessed, literacy rates were low, with one study reporting lower literacy among of-the-street children than on-the-street children [
      • Agnihotri P.
      Street boys of Delhi: A study of their family and demographic characteristics.
      ,
      • Beyene Y.
      • Berhane Y.
      Characteristics of street children in Nazareth, Ethiopia.
      ,
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,

      UNICEF. Street and unsupervised children of Mongolia; 2003. Available at: http://www.unicef.org/mongolia/street_children_Report_Eng.pdf. Accessed April 5, 2013.

      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • Abdelgalil S.
      • Gurgel R.G.
      • Theobald S.
      • et al.
      Household and family characteristics of street children in Aracaju, Brazil.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      ,
      • Ikechebelu J.I.
      • Udigwe G.O.
      • Ezechukwu C.C.
      • et al.
      Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria.
      ,
      • Duyan V.
      Relationships between the sociodemographic and family characteristics, street life experiences and the hopelessness of street children.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Apt N.A.
      • Blavo E.Q.
      Response. Street children and AIDS.
      ]. Children most commonly cited poverty, needing to work, lack of interest, or migration as reasons for leaving school [
      • Ali M.
      • Shahab S.
      • Ushijima H.
      • et al.
      Street children in Pakistan: A situational analysis of social conditions and nutritional status.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Gregson S.
      • Nyamukapa C.A.
      • Garnett G.P.
      • et al.
      HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe.
      ]. Girls may have been denied the opportunity to go to school [
      • Ikechebelu J.I.
      • Udigwe G.O.
      • Ezechukwu C.C.
      • et al.
      Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria.
      ].

      Nutrition and growth

      Fifteen studies (detailed in Table 1, which can be found in the online edition of this article) examined the nutritional and growth effects of being on the street. The literature, primarily conducted in Asian countries, has yielded mixed results. Multiple studies have documented participants' poor nutritional or growth status, primarily using measures of body mass index or stunting [
      • Nzimakwe D.
      • Brookes H.
      An investigation to determine the health status of institutionalised street children in a place of safety in Durban.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Ali M.
      • Shahab S.
      • Ushijima H.
      • et al.
      Street children in Pakistan: A situational analysis of social conditions and nutritional status.
      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      ,
      • D'Abreu R.C.
      • Mullis A.K.
      • Cook L.R.
      The resiliency of street children in Brazil.
      ,
      • Gross R.
      • Landfried B.
      • Herman S.
      Height and weight as a reflection of the nutritional situation of school-aged children working and living in the streets of Jakarta.
      ,
      • Olgar S.
      • Oktem F.
      • Dindar A.
      • et al.
      Volatile solvent abuse caused glomerulopathy and tubulopathy in street children.
      ]. Some studies have found that of-the-street children have poorer nutritional status than on-the-street children, suggesting that street children with ties to family and community have better growth outcomes, whereas others suggest that of-the-street children may fare better in their nutritional and growth status than youth on the margins between home and the street [
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Panter-Brick C.
      • Todd A.
      • Baker R.
      Growth status of homeless Nepali boys: Do they differ from rural and urban controls?.
      ,
      • D'Abreu R.C.
      • Mullis A.K.
      • Cook L.R.
      Social support and the ability to adapt to life among Brazilian street children and non-street children.
      ,
      • Ayaya S.O.
      • Esamai F.O.
      Health problems of street children in Eldoret, Kenya.
      ].
      Of particular note is a series of studies by Panter-Brick and colleagues, who compared on-the-street not only with of-the-street children but also to community controls, including both rural village children and urban, middle-class schoolchildren [
      • Panter-Brick C.
      • Todd A.
      • Baker R.
      Growth status of homeless Nepali boys: Do they differ from rural and urban controls?.
      ,
      • Panter-Brick C.
      • Lunn P.G.
      • Baker R.
      • et al.
      Elevated acute-phase protein in stunted Nepali children reporting low morbidity: Different rural and urban profiles.
      ,
      • Worthman C.
      • Panter-Brick C.
      Homeless street children in Nepal: Use of allostatic load to assess the burden of childhood adversity.
      ]. They found that of-the-street children fared better than on-the-street and rural children based on weight, height, and other nutritional measures. They speculated that of-the-street children may be a self-selected, resilient subgroup of youth who have better access to nutritional sources on the street than in the village. Given their findings, Panter-Brick et al. concluded that “urban homelessness may represent an appropriate response to circumstances of poverty” [
      • Panter-Brick C.
      • Todd A.
      • Baker R.
      Growth status of homeless Nepali boys: Do they differ from rural and urban controls?.
      ].

      Infectious diseases

      Six studies, of which four were conducted in Asia, examined parasitic infections. Parasitic infections, including enteroparasitic infections, were more prevalent among street children than non-street children and among of-the-street children than on-the-street children [
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Poudel S.K.S.
      • Barker S.C.
      Infestation of people with lice in Kathmandu and Pokhara, Nepal.
      ]. One study found that simultaneous pediculosis corporis and capitis infections were more common among street children than schoolchildren [
      • Poudel S.K.S.
      • Barker S.C.
      Infestation of people with lice in Kathmandu and Pokhara, Nepal.
      ]. Other studies found higher prevalence rates of ectoparasitic and enteroparasitic infections among of-the-street than on-the-street children [
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ]. Enteroparasitic infections found in street children included schistosomes, Tricuris, Ascaris, Encheliophis vermicularis, Giardia, Entamoeba, Blastocytes hominis, and Endolimax nana [
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Characterizing health behaviors and infectious disease prevalence among Filipino street children.
      ,
      • Baldo E.T.
      • Belizario V.Y.
      • De Leon W.U.
      • et al.
      Infection status of intestinal parasites in children living in residential institutions in Metro Manila, the Philippines.
      ,
      • Guignard S.
      • Arienti H.
      • Freyre L.
      • et al.
      Prevalence of enteroparasites in a residence for children in the Cordoba Province, Argentina.
      ]. One study found intestinal parasites in 85% of orphaned and of-the-street children [
      • Guignard S.
      • Arienti H.
      • Freyre L.
      • et al.
      Prevalence of enteroparasites in a residence for children in the Cordoba Province, Argentina.
      ].
      Only one study examined the prevalence of bacterial infections among street children, diagnosing 12.3% of their sample of of-the-street children with pneumonia by chest x-ray and clinical evaluation [
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Characterizing health behaviors and infectious disease prevalence among Filipino street children.
      ].
      Although malaria and tuberculosis are leading sources of morbidity and mortality in many low- and middle-income countries and disproportionately impact impoverished populations, no studies addressing malaria or tuberculosis in street children were found [
      • Russell S.
      The economic burden of illness for households in developing countries: A review of studies focusing on malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome.
      ].
      Several studies, primarily in Brazil and Iran, examined rates of hepatic infection among youth. One study examining hepatitis A prevalence among street children found high rates of hepatitis A virus (80.0%–92.2%) among youth, with no statistical difference in rates of anti–hepatitis A virus in on-the-street versus of-the-street youth [
      • Queiróz D.A.
      • Cardoso D.D.
      • Martelli C.M.
      • et al.
      Seroepidemiology of hepatitis A virus infection in street children of Goiânia-Goiás.
      ]. Seven studies tested for hepatitis B prevalence among street children [
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Characterizing health behaviors and infectious disease prevalence among Filipino street children.
      ,
      • Avila M.M.
      • Casanueva E.
      • Piccardo C.
      • et al.
      HIV-1 and Hepatitis B virus infections in adolescents lodged in security institutes of Buenos Aires.
      ,
      • Fallah F.
      • Karimi A.
      • Eslami G.
      • et al.
      The homeless youth and their exposure to hepatitis B and hepatitis C among in Tehran, Iran.
      ]. Exposure to hepatitis B virus, measured by anti–hepatitis B core prevalence, was more common among of-the-street than on-the-street children [
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ]. Three studies reported hepatitis C prevalence rates ranging from 0% to 3.5%, with one study reporting higher hepatitis C virus rates among of-the-street than on-the-street children [
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      ,
      • Fallah F.
      • Karimi A.
      • Eslami G.
      • et al.
      The homeless youth and their exposure to hepatitis B and hepatitis C among in Tehran, Iran.
      ,
      • Martins R.
      • Porto S.
      • Vanderborght B.
      • et al.
      Short report: Prevalence of hepatitis C viral antibody among Brazilian children, adolescents, and street youths.
      ].

      Sexual and reproductive health

      The sexual and reproductive health of street children, including sexual risk behaviors, sexually transmitted infections (STIs) and HIV, is one area of greater, though still incomplete, knowledge. Nineteen studies globally (detailed in Table 2, which can be found in the online edition of this article) tested for or (more frequently) assessed the self-reported history of STIs or HIV among street children.
      Across studies, youth reported an average age of sexual initiation ranging from 10 to 16 years [

      Ramakrishna J, Karott M, Murthy R. Experiences of sexual coercion among street boys in Bangalore, India. In: Bott S, Jejeebhoy S, Shah I, et al, eds. Towards adulthood: Exploring the sexual and reproductive health of adolescents in South Asia. Geneva, Switzerland: 2003. p. 95–98.

      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      ,
      • Anarfi J.K.
      Street youth in Accra city: Sexual networking in a high-risk environment and its implications for the spread of HIV /AIDS.
      ,
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ]. The proportion of sexually active children and youth was markedly greater among of-the-street than on-the-street children, though this finding may be confounded by age differences between the two groups [
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      ].
      Though street-involved youth in low- and middle-income countries are widely cited as being at higher risk for STIs [
      • Dehne K.L.
      • Reidner G.
      Sexually transmitted infections among adolescents.
      ], studies assessing self-reported STI history are few, and only four articles globally reported STI testing with youth (noninclusive of HIV and hepatitis B testing). Among those studies that conducted STI testing, prevalence rates for gonorrhea, chlamydia, syphilis, and genital herpes ranged from 2% to 22% [
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      ]. One study found comparable syphilis prevalence rates in on-the-street and of-the-street children [
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ]. Studies yielded mixed findings on the association between gender and STI prevalence, with one study finding significantly higher STI prevalence among females and another finding higher STI prevalence among males [
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      ]. Risk factors for testing STI-positive included sleeping on the streets, drug use, older age, female gender, and survival sex [
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      ]. There were no data reporting rates of trichomoniasis. Hepatitis B, discussed in the prior section, is included in Table 2.
      Eight studies, detailed in Table 2 and conducted exclusively in Russia, Iran, and South America, tested street children for HIV [
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Avila M.M.
      • Casanueva E.
      • Piccardo C.
      • et al.
      HIV-1 and Hepatitis B virus infections in adolescents lodged in security institutes of Buenos Aires.
      ,
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      ,
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      ,
      • Kissin D.M.
      • Zapata L.
      • Yorick R.
      • et al.
      HIV seroprevalence in street youth, St Petersburg, Russia.
      ,
      • Lambert M.L.
      • Torrico F.
      • Billot C.
      • et al.
      Street youths are the only high-risk group for HIV in a low-prevalence South American country.
      ]. HIV prevalence in these studies was uniformly several-fold greater than corresponding population rates of HIV [
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      ,
      • Kissin D.M.
      • Zapata L.
      • Yorick R.
      • et al.
      HIV seroprevalence in street youth, St Petersburg, Russia.
      ,
      • Lambert M.L.
      • Torrico F.
      • Billot C.
      • et al.
      Street youths are the only high-risk group for HIV in a low-prevalence South American country.
      ]. In one study, street youth rates were higher than those of commercial sex workers, truck drivers, or prisoners [
      • Lambert M.L.
      • Torrico F.
      • Billot C.
      • et al.
      Street youths are the only high-risk group for HIV in a low-prevalence South American country.
      ]. The strongest independent predictors of seropositivity among street youth were: older age, using injection drugs, using non-injection drugs (Stadol, inhalant, ephedrine), orphanhood, being of-the-street, having “no place to live or living in an attic or basement,” being recruited from a street rather than service setting, having multiple partners, and reporting a previous STI diagnosis [
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      ,
      • Kissin D.M.
      • Zapata L.
      • Yorick R.
      • et al.
      HIV seroprevalence in street youth, St Petersburg, Russia.
      ,
      • Lambert M.L.
      • Torrico F.
      • Billot C.
      • et al.
      Street youths are the only high-risk group for HIV in a low-prevalence South American country.
      ].

      Unintentional injuries

      One multinational study quantifying injuries sustained by street children found high rates of physical injury [
      • Pinzon-Rondon A.M.
      • Koblinsky S.A.
      • Hofferth S.L.
      • et al.
      Work-related injuries among child street-laborers in Latin America: Prevalence and predictors.
      ]. Forty percent of street children reported work-related injuries, including scratches, cuts and lacerations, burns, sprains, and amputations. Longer work hours, working as a street performer, male gender, and older age were associated with increased risk of injury.

      Violence

      Violence and sexual abuse were ubiquitous in the worlds of street children. Street children commonly reported experiencing physical violence, verbal abuse, and monetary extortion by peers and adults, including parents, other relatives, police, and sex work clients [
      • Nada K.H.
      • Suliman E.D.A.
      Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.
      ,
      • Agnihotri P.
      Street boys of Delhi: A study of their family and demographic characteristics.
      ,
      • Sherman S.S.
      • Plitt S.
      • ul Hassan S.
      • et al.
      Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan.
      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Pagare D.
      • Meena G.
      • Singh M.
      • et al.
      Risk factors of substance use among street children from Delhi.
      ,

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      ,
      • Seager J.R.
      • Tamasane T.
      Health and well-being of the homeless in South African cities and towns.
      ,
      • Ikechebelu J.I.
      • Udigwe G.O.
      • Ezechukwu C.C.
      • et al.
      Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria.
      ,
      • Banerjee S.R.
      Physical abuse of street and slum children of Kolkata.
      ,
      • Khurana S.
      • Sharma N.
      • Jena S.
      • et al.
      Mental health status of runaway adolescents.
      ,
      • Ribeiro M.O.
      Street children and their relationship with the police.
      ,
      • McAlpine K.
      • Henley R.
      • Mueller M.
      • et al.
      A survey of street children in Northern Tanzania: How abuse or support factors may influence migration to the street.
      ,
      • Scivoletto S.
      • da Silva T.F.
      • Rosenheck R.A.
      Child psychiatry takes to the streets: A developmental partnership between a university institute and children and adolescents from the streets of Sao Paulo, Brazil.
      ]. Despite international recognition of the frequent harm to street children by police, rates of police abuse of street children are unknown [
      • Brooke J.
      Gunmen said to be police kill 7 street children in Rio.
      ,

      UNICEF. The state of the world's children 2006: Excluded and invisible: United Nations Publications Report No.: 9280639161; 2005.

      ,
      • Pinheiro P.
      United Nations Secretary-General's Study on Violence Against Children.
      ].
      Study participants worldwide commonly reported experiencing sexual abuse by peers and adults [
      • Nada K.H.
      • Suliman E.D.A.
      Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.
      ,

      Ramakrishna J, Karott M, Murthy R. Experiences of sexual coercion among street boys in Bangalore, India. In: Bott S, Jejeebhoy S, Shah I, et al, eds. Towards adulthood: Exploring the sexual and reproductive health of adolescents in South Asia. Geneva, Switzerland: 2003. p. 95–98.

      ,
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      ,
      • Wutoh A.K.
      • Kumoji E.K.
      • Xue Z.Y.
      • et al.
      HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana.
      ,
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      ,
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      ,
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Tiwari P.
      Life on streets.
      ,
      • Pagare D.
      • Meena G.S.
      • Jiloha R.C.
      • et al.
      Sexual abuse of street children brought to an observation home.
      ,

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      ,
      • Lee J.A.B.
      • Odie-Alie S.
      Carry me home: A collaborative study of street children in Georgetown, Guyana.
      ,
      • Seager J.R.
      • Tamasane T.
      Health and well-being of the homeless in South African cities and towns.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      ,
      • Ikechebelu J.I.
      • Udigwe G.O.
      • Ezechukwu C.C.
      • et al.
      Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      ,
      • Khurana S.
      • Sharma N.
      • Jena S.
      • et al.
      Mental health status of runaway adolescents.
      ,
      • Ribeiro M.O.
      Street children and their relationship with the police.
      ,
      • Scivoletto S.
      • da Silva T.F.
      • Rosenheck R.A.
      Child psychiatry takes to the streets: A developmental partnership between a university institute and children and adolescents from the streets of Sao Paulo, Brazil.
      ,
      • Aral S.O.
      • St Lawrence J.S.
      • Dyatlov R.
      • et al.
      Commercial sex work, drug use, and sexually transmitted infections in St. Petersburg, Russia.
      ,
      • Ahmadkhaniha H.R.
      • Shariat S.V.
      • Torkaman-nejad S.
      • et al.
      The frequency of sexual abuse and depression in a sample of street children of one of deprived districts of Tehran.
      ,
      • Malamud S.
      At risk and abandoned: Street children, AIDS and human rights.
      ]. The prevalence of sexual abuse for girls may be particularly high; in one study, 42% of street girls reported that their first sexual experience was forced [
      • Wutoh A.K.
      • Kumoji E.K.
      • Xue Z.Y.
      • et al.
      HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana.
      ].
      Street children reported widely ranging rates of survival sex, the practice of exchanging sex for money, drugs, shelter, or protection [
      • Sherman S.S.
      • Plitt S.
      • ul Hassan S.
      • et al.
      Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan.
      ,
      • Wutoh A.K.
      • Kumoji E.K.
      • Xue Z.Y.
      • et al.
      HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana.
      ,
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      ,
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Raffaelli M.
      • Siqueira E.
      • Paynemerritt A.
      • et al.
      HIV-related knowledge and risk behaviors of street youth in Belo-Horizonte, Brazil.
      ,
      • Anarfi J.K.
      Street youth in Accra city: Sexual networking in a high-risk environment and its implications for the spread of HIV /AIDS.
      ,
      • Towe V.L.
      • ul Hasan S.
      • Zafar S.T.
      • et al.
      Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.
      ,
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Robbins C.
      • Zapata L.
      • Kissin D.
      • et al.
      Multicity HIV seroprevalence in street youth, Ukraine.
      ]. Girls more frequently reported engaging in survival sex than boys [
      • Wutoh A.K.
      • Kumoji E.K.
      • Xue Z.Y.
      • et al.
      HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana.
      ,
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      ,
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      ,
      • Ntozi J.P.
      • Najjumba I.M.
      • Ahimbisibwe F.
      • et al.
      Has the HIV/AIDS epidemic changed sexual behaviour of high risk groups in Uganda?.
      ,
      • Tahmina Q.
      • Moral S.
      Sex-workers in Bangladesh, Livelihood, at what Price?.
      ]. In addition, one study found that of-the-street children were significantly more likely to report survival sex than on-the-street children [
      • Merrill R.M.
      • Njord L.
      • Njord R.
      • et al.
      The effect of family influence on indicators associated with street life among Filipino street children.
      ].

      Mental health

      Few nonethnographic studies have systematically addressed the mental health needs of street children. Internalizing and externalizing behaviors were mentioned frequently throughout the literature without rigorous description of diagnostic criteria or use of validated testing tools. Traumatic experiences were frequently described, but studies measuring posttraumatic stress disorder using standardized diagnostic tools were not found.
      Chronic exposure to stressors puts individuals at risk for hopelessness, depression, and suicide. Eight studies evaluated street youth's experiences of hopelessness, depressive symptoms, self-harm, and suicidality. Studies used different measures, making results difficult to compare. Overall, studies indicated that street children experience high levels of hopelessness, vulnerability to depression, and depressive symptoms [
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Seager J.R.
      • Tamasane T.
      Health and well-being of the homeless in South African cities and towns.
      ,
      • Merrill R.M.
      • Njord L.
      • Njord R.
      • et al.
      The effect of family influence on indicators associated with street life among Filipino street children.
      ,
      • Techakasem P.
      • Kolkijkovin V.
      Runaway youths and correlating factors, study in Thailand.
      ]. Two studies found that of-the-street were more likely than on-the-street children to report feelings of hopelessness [
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Merrill R.M.
      • Njord L.
      • Njord R.
      • et al.
      The effect of family influence on indicators associated with street life among Filipino street children.
      ]. Another study found that of-the-street children had significantly lower self-efficacy scores and ability to deal with problems than did their on-the-street counterparts [
      • Sta Maria M.
      Concomitants of risk and protection among Filipino street youth.
      ]. Suicide attempts were reported across studies by 2% to 23% of street children, with one study reporting higher rates of suicidality among of-the-street than on-the-street children [
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Merrill R.M.
      • Njord L.
      • Njord R.
      • et al.
      The effect of family influence on indicators associated with street life among Filipino street children.
      ,
      • Techakasem P.
      • Kolkijkovin V.
      Runaway youths and correlating factors, study in Thailand.
      ]. Risk factors for self-harm and suicidal behaviors included female gender, reported history of physical or sexual abuse, and engagement in survival sex [
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ].

      Substance use and abuse

      Substance use (detailed in Table 3, which can be found in the online edition of this article) was the most common topic in the literature reviewed. We have summarized only the articles principally focused on street children's drug use. The published prevalence of drug use ranged widely, from 35% to 100%. Street youth reported that they used drugs to fit in on the street; cope with street life, sexual abuse, violence and/or survival sex; numb emotions; curb hunger; keep warm; induce or prevent sleep; feel pleasure; or for entertainment [
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      ,
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ,
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Lee J.A.B.
      • Odie-Alie S.
      Carry me home: A collaborative study of street children in Georgetown, Guyana.
      ,
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      ,
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Drug use among street children and non—street children in the Philippines.
      ,
      • Jutkowitz J.M.
      • Spielmann H.
      • Koehler U.
      • et al.
      Drug use in Nepal: The view from the street.
      ].
      In the majority of studies, the average age of drug use initiation was 10 to 13 years, with earlier initiation reported among of-the-street than on-the-street children [
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Pagare D.
      • Meena G.
      • Singh M.
      • et al.
      Risk factors of substance use among street children from Delhi.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Drug use among street children and non—street children in the Philippines.
      ]. Street children commonly reported being introduced to substance use by family members and peers [
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ]. Stated reasons for initiation included emotional problems, curiosity, pleasure-seeking, and peer pressure [
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ].
      Factors associated with current drug use included older age; male gender; increased hours on the street; duration of life on the street; depression, especially among girls; child abuse; out-of-school status; lack of family contact; unprotected sex; survival sex; having had sex; higher numbers of sex partners; STI history; having had an HIV test; perceiving oneself to be HIV positive; and having an HIV-positive friend [
      • Nada K.H.
      • Suliman E.D.A.
      Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.
      ,
      • Sherman S.S.
      • Plitt S.
      • ul Hassan S.
      • et al.
      Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan.
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Pagare D.
      • Meena G.
      • Singh M.
      • et al.
      Risk factors of substance use among street children from Delhi.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      ,
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      ,
      • Towe V.L.
      • ul Hasan S.
      • Zafar S.T.
      • et al.
      Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      ,
      • Obando P.
      • Kliewer W.
      • Murrelle L.
      • et al.
      The comorbidity of substance abuse and depressive symptoms in Costa Rican adolescents.
      ]. Across studies, of-the-street children were significantly more likely to report current drug use than their on-the-street counterparts [
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      ,
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      ,
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Merrill R.M.
      • Njord L.
      • Njord R.
      • et al.
      The effect of family influence on indicators associated with street life among Filipino street children.
      ,
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Drug use among street children and non—street children in the Philippines.
      ].
      Street children most commonly reported using cigarettes, inhalants, alcohol, and marijuana. Other substances included kola nut, coca paste, cocaine, amphetamines, and heroin [
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      ,
      • Tiwari P.
      Life on streets.
      ,
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Raffaelli M.
      • Siqueira E.
      • Paynemerritt A.
      • et al.
      HIV-related knowledge and risk behaviors of street youth in Belo-Horizonte, Brazil.
      ,
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      ,
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      ,
      • Towe V.L.
      • ul Hasan S.
      • Zafar S.T.
      • et al.
      Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Avila M.M.
      • Casanueva E.
      • Piccardo C.
      • et al.
      HIV-1 and Hepatitis B virus infections in adolescents lodged in security institutes of Buenos Aires.
      ,
      • Jutkowitz J.M.
      • Spielmann H.
      • Koehler U.
      • et al.
      Drug use in Nepal: The view from the street.
      ]. Injection drug use was generally more common in middle-income countries, among males, and among of-the-street versus on-the-street children [
      • Nada K.H.
      • Suliman E.D.A.
      Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.
      ,
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      ,
      • Raffaelli M.
      • Siqueira E.
      • Paynemerritt A.
      • et al.
      HIV-related knowledge and risk behaviors of street youth in Belo-Horizonte, Brazil.
      ,
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Avila M.M.
      • Casanueva E.
      • Piccardo C.
      • et al.
      HIV-1 and Hepatitis B virus infections in adolescents lodged in security institutes of Buenos Aires.
      ,
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      ,
      • Zapata L.B.
      • Kissin D.M.
      • Robbins C.L.
      • et al.
      Multi-city assessment of lifetime pregnancy involvement among street youth, Ukraine.
      ].
      There is an inhalant use epidemic in low- and middle-income countries. Inhalants, such as shoemaker's glue, paint thinner, and correction fluid, are inexpensive, ubiquitous, and may cost less than food while suppressing appetite [
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      ,
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      ,
      • Olgar S.
      • Oktem F.
      • Dindar A.
      • et al.
      Volatile solvent abuse caused glomerulopathy and tubulopathy in street children.
      ,
      • Olgar S.
      • Dindar A.
      • Ertugrul T.
      • et al.
      Electrocardiographic and echocardiographic findings in street children known to be substance abusers.
      ]. The health effects of chronic ingestion of toluene, the main ingredient in most inhalants, include cardiotoxicity, neurotoxicity, hepatoxicity, hematologic toxicity, glomerulopathy, and tubulopathies leading to both metabolic and renal tubular acidosis [
      • Olgar S.
      • Oktem F.
      • Dindar A.
      • et al.
      Volatile solvent abuse caused glomerulopathy and tubulopathy in street children.
      ,
      • Olgar S.
      • Dindar A.
      • Ertugrul T.
      • et al.
      Electrocardiographic and echocardiographic findings in street children known to be substance abusers.
      ]. One study has noted that it can be difficult to detect intoxication among street children who have built up tolerance for inhalants and suggested screening for inhalant use by detecting toluene metabolized to urine hippuric acid [
      • Thiesen F.V.
      • Noto A.R.
      • Barros H.M.T.
      Laboratory diagnosis of toluene-based inhalants abuse.
      ].

      Health care

      Street children reported limited access to health care. Barriers included cost, minority status, stigmatization by providers, distrust in quality of care, and difficulty finding time to seek care because of lost earnings [
      • Ali A.
      • de Muynck A.
      Illness incidence and health seeking behaviour among street children in Rawalpindi and Islamabad, Pakistan - a qualitative study.
      ,
      • Ruiz J.
      Street youth in Colombia: Lifestyle, attitudes and knowledge. AIDS health promotion exchange/World Health Organization, Global Programme on AIDS.
      ,
      • Anarfi J.K.
      Vulnerability to sexually transmitted disease: Street children in Accra.
      ]. Two studies found that a majority of street youth did not seek medical help for ailments, instead ignoring their symptoms or self-medicating when ill [
      • Anarfi J.K.
      Vulnerability to sexually transmitted disease: Street children in Accra.
      ,
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      ]. As a measure of access to primary care, one study found that street children were one fifth as likely to have been vaccinated for measles as slum children living with their parents [
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      ]. We found no other data regarding vaccination rates among street children. Studies examining the dental health of street children found that children's teeth were in poor condition and that children had an unmet need for dental care, particularly for caries and tooth loss [
      • Nzimakwe D.
      • Brookes H.
      An investigation to determine the health status of institutionalised street children in a place of safety in Durban.
      ,
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      ,
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      ,
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      ,
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      ,
      • Ayaya S.O.
      • Esamai F.O.
      Health problems of street children in Eldoret, Kenya.
      ,
      • Contreras-Bulnes R.
      • Reyes-Silveyra L.J.
      • Fuentes-Alvarez T.
      • et al.
      Dental caries and treatment needs in street children in Toluca, Mexico.
      ,
      • Dogan M.C.
      • Haytac M.C.
      • Ozali O.
      • et al.
      The oral health status of street children in Adana, Turkey.
      ,
      • Kahabuka F.K.
      • Mbawalla H.S.
      Oral health knowledge and practices among Dar es Salaam institutionalized former street children aged 7-16 years.
      ].

      Burden of disease

      No formal data documenting mortality rates or causes of death of street children were found in our review. Limited data were found documenting life expectancy or burden and types of chronic illness in street children.
      One study examined the burden of disease among street children by measuring antichymotrypsin as a marker for the inflammation due to repeated and chronic infections as well as by measuring allostatic load as a marker of stress. Antichymotrypsin and allostatic load were highest in housed rural village children, followed by, in decreasing order, of-the-street children, on-the-street schoolchildren, and middle class schoolchildren [
      • Panter-Brick C.
      • Lunn P.G.
      • Baker R.
      • et al.
      Elevated acute-phase protein in stunted Nepali children reporting low morbidity: Different rural and urban profiles.
      ].

      Discussion

      Our review has limitations, most predominantly our limitation to studies published in English. Though we reviewed studies in French and Spanish, none met our inclusion criteria. Similarly, though we searched 18 databases, publications not included in those databases would not have been included, and within the databases, our search terms may have missed some studies. Our sources from the gray literature were primarily found through references and nonsystematic web searches and so are not comprehensive. Finally, a major limitation of many of the articles reviewed and thus of our review is that the majority did not incorporate community controls or overall community comparisons. Thus, although existing data suggest that street youth suffer disproportionate morbidity, we were unable to provide direct comparisons against the adolescent population overall for all outcomes reviewed.
      Street children serve as a compelling example of the global disparity in child health. The available literature paints a picture of children who, often in response to circumstances at the structural and familial level, engage disproportionately in high-risk behaviors. These risk behaviors include not only those behaviors also engaged in by youths' non-homeless counterparts (such as early sexual debut or experimentation with substances) but, more importantly, very high-risk behaviors that are not normative in any setting (such as survival sex or substance dependence). These behaviors and the exposures associated with poor shelter have resulted in disproportionate morbidity in the areas of infectious illness, psychiatric disease, reproductive health, and, perhaps to a lesser extent, growth.

      Implications for a future research agenda

      Findings from our review, as well as several notable gaps and limitations in the current research, suggest a number of next steps. Based on these findings and gaps, we offer the following principles to inform future research regarding street children in low- and middle-income nations. We hope this article will inform future research and provide support for an evidence-based dialogue among researchers, child advocates, and policymakers.
      More data are needed. Although our review included 108 studies regarding street child health, data regarding specific health topics are sparse, vary considerably by region, and are often inadequate for developing evidence-based approaches. For example, there are far more published data regarding STIs and HIV among street children in South America and Russia than from other regions of the world, and only 12 studies globally that conducted STI or HIV testing with street children. Though the available data are compelling, there is a need for data from other highly HIV-impacted regions of the world to inform policy and interventions. Similarly, data regarding growth and development have had contradictory conclusions regarding the effect of being street-based and have been gathered primarily from South Asia. In addition, vast areas of health that may disproportionately affect street children in childhood or as adults have not been investigated, including cognitive deficits and chronic diseases like malaria and tuberculosis. Likewise, the burden of years of productive life lost in this population is likely great, but has not been estimated.
      There is a need for standardization of definitions of street youth to allow for comparisons across studies [

      UNICEF Executive Board. Exploitation of working children and street children. U.N. Doc. E/ICEF/1986/CRP.1983; 1986.

      ]. We acknowledge that all terms are hampered by the fact that children are not static and may frequently move between groups. In addition, there is a need for standardized measures of health, including measures of the social determinants of health across studies within this population [
      • Sawyer S.M.
      • Afifi R.A.
      • Bearinger L.H.
      • et al.
      Adolescence: A foundation for future health.
      ]. Our review particularly noted a lack of standardized diagnostic criteria in studies of mental health.
      There is a need for an expansion of quantitative studies of street children's health, including surveys, clinical studies, and evidence-based public health interventions. Given the importance of environmental and social contexts in child and adolescent health and development, there is a need for studies that go beyond the descriptive to the explanatory, including elucidating the structural mediators for of street children's poor health outcomes.
      There is a need for more rigorous study design and recruitment. Most studies reviewed relied on cross-sectional convenience samples recruited from service settings. Studies are needed that make use of more rigorous sampling and recruitment methods in order to reach less visible subpopulations of street children and youth, whose needs and health status may be significantly different from those reached by convenience sampling. Investigators would do well to learn from studies of other hard-to-reach and marginalized populations in low- and middle-income nations that are employing novel methods to sample participants and document social determinants of health and health status [
      • Lane T.
      • Raymond H.F.
      • Dladla S.
      • et al.
      High HIV prevalence among men who have sex with men in Soweto, South Africa: Results from the Soweto Men's Study.
      ,
      • Raymond H.F.
      • Kajubi P.
      • Kamya M.R.
      • et al.
      Correlates of unprotected receptive anal intercourse among gay and bisexual men: Kampala, Uganda.
      ,
      • Auerswald C.
      • Kwena Z.A.
      • Ochieng J.H.
      • et al.
      Feasibility of employing respondent-driven sampling for HIV/STI testing of street children: Experience from the Vijana Wetu pilot study in Kisumu, Kenya.
      ]. In addition, there is a critical need for longitudinal studies to answer basic questions regarding street youths' life course, such as whether they grow up to be street-based adults or whether being street-based is simply a rite of passage for children in the many marginalized families living in the rapidly expanding cities of low- and middle-income nations. One particular strength of the existing literature has been investigators' clear collaborative efforts with community partners. These street-based partners frequently have longitudinal relationships with children. Continued community-based research in collaboration with such programs may facilitate the collection of longitudinal data from cohorts of street youth. Finally, future studies would be further strengthened by the inclusion of community-based controls of non–street-based children. The work of Panter-Brick and colleagues stands out in this regard.
      Programs to reintegrate youth into their communities need to be developed that are appropriate to local settings and recognize the universal human rights of children [

      United Nations. Convention on the Rights of the Child. 1990. Available at: http://www.unicef.org/crc/. Accessed April 5, 2013.

      ]. Our findings strongly support the conclusion that of-the-street youth have poorer health outcomes than on-the-street youth, particularly regarding infectious diseases and STIs, reproductive health, mental health and substance abuse, and violence. This suggests that the provision of safe shelter must be a primary intervention to improve the health of these youth. Based on our findings, interventions such as increased access to education for street-based children, the regulation of access to inhalants, and the enforcement of laws protecting all children from physical and sexual abuse and neglect (as codified in the United Nations Convention of the Rights of the Child), are also indicated [
      • Viner R.M.
      • Ozer E.M.
      • Denny S.
      • et al.
      Adolescence and the social determinants of health.
      ]. Youths' resilience and need for independence to survive under particularly harsh circumstances should be recognized. However, it is also imperative to recognize the fiduciary responsibility and shared interest of communities at the local and global level to support youth in becoming productive, healthy adults.

      Acknowledgments

      We gratefully acknowledge the support of David Cash for his invaluable assistance in locating and managing sources and in the drafting of this manuscript. All individuals who have contributed significantly to the work have been listed here. This article was supported by University of California San Francisco Department of Pediatrics Chairman's Funds for J.W. and J.L.

      Appendix

      Table 1Nutritional and growth status of street children in low- and middle-income countries
      Country (city)Author, yearSampleSourceGender (% male)Mean age in years (range)
      Unless otherwise specified.
      Results
      Brazil (Rio de Janeiro)D'Abreu, 1999
      • D'Abreu R.C.
      • Mullis A.K.
      • Cook L.R.
      The resiliency of street children in Brazil.
      N = 60 (30 “on” and “of”; 30 control school children)Street

      Service programs

      School
      10015.6 (13–18)BMI of control school children: 21.19

      BMI of street-based children: 15.54
      Brazil (Belo Horizonte)Pinto, 1994
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      N = 394 (199 “on”; 195 “of”)Government shelterTotal sample: 71

      “On:” 62

      “Of:” 80
      13.3 (10–18)Mean BMI: 18.9

      A high proportion classified as chronic energy deficiency II and III, (16% “of"/18% "on"; 10% “of”/11% “on”)
      Honduras (Tegucigalpa)Wittig, 1997
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      N = 1,244 (1,084 “on”; 160 “of”)StreetTotal sample: 58

      “On:” 53; “Of:” 95
      “On:” 10

      “Of:” 13
      Of-the-street inhalant users more likely than nonusers to be assessed by interviewers as having “fair” or “poor” nutritional status (28.9% vs. 20.5%)
      Bangladesh (Dhaka)Greksa, 2007
      • Greksa L.P.
      • Rie N.
      • Islam A.B.
      • et al.
      Growth and health status of street children in Dhaka, Bangladesh.
      N = 292 (150 “on”; 142 “of”)Street“On:” 50

      “Of:” 52
      (7–14)

      Median ages: male “on” 11.0; male “of” 11.5; female “on” 10.0; female “of” 10.0
      Majority of both of- and on-the-street children stunted and underweight, with no significant difference between groups. Of-the-street had larger fat deposits than on-the-street children

      Boys significantly taller, leaner and less stunted than girls

      No wasting seen in either of- or on-the-street children
      Indonesia (Jakarta)Gross, 1996
      • Gross R.
      • Landfried B.
      • Herman S.
      Height and weight as a reflection of the nutritional situation of school-aged children working and living in the streets of Jakarta.
      N = 89 (79% “on”; 21% “of”)Street88(8–15)52% stunted (height-for-age below 3rd centile)

      7% wasted (weight-for-height below 3rd centile)
      Nepal (Kathmandu; rural village)Panter-Brick, 1996
      • Panter-Brick C.
      • Todd A.
      • Baker R.
      Growth status of homeless Nepali boys: Do they differ from rural and urban controls?.
      N = 307 (62 “on”; 111 “of”; 52 village controls; 82 middle-class schoolchild controls)Street

      Service program

      School
      100(6–14)On- and of-the-street boys had high proportions of mild stunting (13%/20%, respectively), moderate stunting (50%/43%), and severe stunting (34%/23%)

      Of-the-street less stunted than on-the-street and village boys. Only middle-class boys not stunted
      Nepal (Kathmandu; rural village)Worthman and Panter-Brick, 2008
      • Worthman C.
      • Panter-Brick C.
      Homeless street children in Nepal: Use of allostatic load to assess the burden of childhood adversity.
      N = 107 (20 “on”; 27 “of”; 30 middle-class school child controls; 30 village child controls)Street

      Service program

      School
      10011.8 (10–14)Of-the-street had better nutritional status (weight for age) than on-the-street boys but no difference in growth status (height for age)

      Of-the-street boys did not have significantly different nutritional or growth status from village controls

      Of-the-street boys had better nutritional status and poorer growth status than schoolchild controls

      Of-the-street boys who had been on the streets for <2 years had better nutritional status than those who had been on the streets for >2 years but did not differ significantly in growth status
      Nepal (Dharan)Thapa, 2009
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      N = 48 (77.1% “on”; 22.9% “of”)NR95.8Most (68.8%) 11–1543.8% underweight by CDC 2000 standards
      PakistanAli, 2004
      • Ali M.
      • Shahab S.
      • Ushijima H.
      • et al.
      Street children in Pakistan: A situational analysis of social conditions and nutritional status.
      N = 108 (101 “on”; 7 “of”)Street81(4–13)

      Girls: 5–11

      Boys: 4–13
      20% stunted; 25% undernourished; 2% wasted

      Boys more likely than girls to be stunted (23% vs. 6%) and undernourished (27% vs. 18%)
      PhilippinesNjord, 2008
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Characterizing health behaviors and infectious disease prevalence among Filipino street children.
      N = 179Service program6012.8BMI of males: 15.6

      BMI of females: 15.8
      Turkey (Istanbul)Olgar, 2008
      • Olgar S.
      • Oktem F.
      • Dindar A.
      • et al.
      Volatile solvent abuse caused glomerulopathy and tubulopathy in street children.
      N = 97 (48 street-based, inhalant-using children; 49 healthy controls living with family)Government shelter

      Case control (control source not reported)
      100Street: 16.24

      Control: 16.96
      Inhalant-using street-based children were shorter than control children (160.8 ± 8 cm vs. 172 ± 6.96 cm, respectively) and weighed less than controls (53.2 ± 10.8 kg vs. 72.7 ± 12.6 kg)
      Turkey (Adana)Turkmen, 2004
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      N = 52 (89% “on”; 11% “of”)

      N = 39 for subset undergoing physical exam
      Service program (drop-in shelter)96.0Median age 14 (7–18)67% under the 50th percentile for height (Turkish standard)

      97% below the 50th percentile for weight, including 19% under 3rd percentile
      Egypt (Alexandria)Salem, 2002
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      N = 100Street

      Shelter
      10013.7 (7–16)83% malnourished (“wasting and stunting”)

      78% anemic
      Kenya (Eldoret)Ayaya, 2001
      • Ayaya S.O.
      • Esamai F.O.
      Health problems of street children in Eldoret, Kenya.
      N = 191 (38 “on”; 47 “of”; 56 abandoned and in shelter; 50 schoolchildren)Street (snowball sample)

      School

      Case control
      NR14 (5–22)Shelter and on-the-street children more likely to be undernourished than of-the-street or schoolchildren (64.3%/55.3%/27.7%/20%, respectively), as well as more stunted (51.8%/44.7%/17.4%/20%)
      South Africa (Durban)Nzimakwe, 1994
      • Nzimakwe D.
      • Brookes H.
      An investigation to determine the health status of institutionalised street children in a place of safety in Durban.
      N = 50Shelter (“place of safety”)8013.8 (12–16)All girls above the 3rd percentile for weight; 60% below the 3rd percentile for height

      37.5% of boys below the 3rd percentile for weight; 62.5% below the 3rd percentile for height

      Malnutrition: 20% girls; 27.5% boys
      BMI = body mass index; CDC = Centers for Disease Control and Prevention; NR = not reported.
      a Unless otherwise specified.
      Table 2Sexually transmitted infections and HIV in street children in low- and middle-income countries
      Country (city)Author, yearSample sizeSourceGender (% male)Mean age in years (range)
      Unless otherwise specified.
      Data sourceResults
      Argentina (Buenos Aires)Avila, 1996
      • Avila M.M.
      • Casanueva E.
      • Piccardo C.
      • et al.
      HIV-1 and Hepatitis B virus infections in adolescents lodged in security institutes of Buenos Aires.
      N = 1,460Detention centers (“Security Institute”)81.016.6 (12–20)SerologyHIV: 4.58%

      HBV: 6.78%

      HIV and HBV prevalence higher among males than females

      Drug users (IDU and non-IDU) more likely to be HIV-positive than nonusers (OR = 2.3)

      IDUs more likely to be HIV-positive (OR = 16.84) and HBV-positive (OR = 3.17) than non-IDUs
      Bolivia (Cochabamba)Lambert, 2005
      • Lambert M.L.
      • Torrico F.
      • Billot C.
      • et al.
      Street youths are the only high-risk group for HIV in a low-prevalence South American country.
      N = 536Street

      Shelter
      75.9Boys: median age 18

      Girls: median age 15
      SerologyHIV: 2.1% (0% among youth under 15; 3.5% among youth 15 and older)
      Brazil (Porto Alegre)de Carvalho, 2006
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      N = 161Service programs (drop-in “Service Centers”)79.514 (Interquartile range 13, 17)Self-reportAmong youth who had ever had sex (N = 95), 9.5% reported having been diagnosed with an STI in the past year

      Among youth who reported having had an HIV test in their lifetime (N = 66), 9.0% reported testing HIV positive and 13.6% did not know the result of their test
      Brazil (Belo Horizonte)Pinto, 1994
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      N = 394 (199 “on”; 195 “of”)Government shelterTotal sample: 71

      “On:” 62

      “Of:” 80
      13.3 (10–18)Serology

      Self-report
      STI history (self-reported): 11% on-the-street; 22% of-the-street

      HIV: 0% “on”; 2.1% “of”

      Syphilis: 2.0% “on”; 2.6% “of” (also reported in tables as 2.5% “on”/3.1% “of”)

      Hepatitis B: 11.1% “on”; 14.9% “of”

      Genital lesions: 12% “on”; 8% “of”
      Brazil (Goiania)Porto, 1994
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      N = 496 (395 “on”; 101 “of”)Street

      Service programs (state institutions)
      Total sample: 93.3

      “On:” 76.2

      “Of:” 97.7
      “On:” 13.6 (SD 2.2)

      “Of:” 14.3 (SD 2.2)
      Serology

      Self-report
      STI history (self-reported): 13.4%

      Hepatitis B:

      Anti-HBc: 13.5%

      HBsAg: 2.0%

      Anti-HBs: 5.4%

      Anti-HBc IgM: 0%

      In multivariate analysis, of- significantly more likely than on-the-street children to be anti-HBc positive
      Russia (St. Petersburg)Aral, 2005
      • Aral S.O.
      • St Lawrence J.S.
      • Dyatlov R.
      • et al.
      Commercial sex work, drug use, and sexually transmitted infections in St. Petersburg, Russia.
      NRChart review0(12–14)Retrospective chart reviewSTI-positive: 86%

      Primary or secondary syphilis: 14%
      Russia (St. Petersburg)Kissin, 2007
      • Kissin D.M.
      • Zapata L.
      • Yorick R.
      • et al.
      HIV seroprevalence in street youth, St Petersburg, Russia.
      N = 313Street locations randomly selected from sampling frame63(15–19)SerologyHIV: 37.4%
      Russia (Moscow)Shakarishvili, 2005
      • Shakarishvili A.
      • Dubovskaya L.K.
      • Zohrabyan L.S.
      • et al.
      Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.
      N = 401Juvenile detention center50(15–17)Serum and urine samplesHIV: 2%

      Syphilis: 7%

      HSV2: 8%

      Gonorrhea: 22%

      Chlamydia: 20%

      HIV rates not significantly different between males and females (2.7% males vs. 1.1% females)

      Females significantly more likely to have one or more bacterial STIs than males (58% vs. 25%)

      Females reporting sex work had higher rates of chlamydia (43% vs. 22%), syphilis (18% vs. 7%), and bacterial STIs (63% vs. 43%) than females who did not report sex work
      Ukraine (Odessa, Kiev, Donetsk)Hillis, 2011
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      N = 929 (20% housed non-orphan; 37% homeless non-orphan; 11% housed orphan; 32% homeless orphan)Street (time-location sampling)76(15–24)SerologyHIV: 7% among housed non-orphans; 16% in homeless non-orphans; 17% in housed orphans; 28% in homeless orphans
      India (Kolkata)Bal, 2010
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      N = 554Street65Median age 13 (50% between 11 and 15)SerologyHIV: 1% (n = 6; 1 female/5 male)

      Syphilis: 4% (n = 22; 7 female/15 male)

      Males were significantly more likely than females to test positive for HIV and syphilis
      Iran (Tehran)Fallah, 2008
      • Fallah F.
      • Karimi A.
      • Eslami G.
      • et al.
      The homeless youth and their exposure to hepatitis B and hepatitis C among in Tehran, Iran.
      N = 203Service program96.6(7–18)SerologyHBV:

      HBsAg positive: 3%

      HBsAb positive: 26.6%

      HBcAb positive: 8%

      HCV: 3.5%
      Iran (Tehran)Vahdani, 2006
      • Vahdani P.
      • Hosseini-Moghaddam S.M.
      • Gachkar L.
      • et al.
      Prevalence of hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis among street children residing in southern Tehran, Iran.
      N = 102Service program38.010.1 (SD 3.0)Serology and self-reportHIV: 0%

      Syphilis: 0%

      HCV: 0%

      HBV:

      HBsAg positive: 3%

      Anti-HBsAb: 15%
      Philippines (Manila)Njord, 2008
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Characterizing health behaviors and infectious disease prevalence among Filipino street children.
      N = 179Service program60.012.8 (8–17)SerologyHBV: 7.9%
      Turkey (Adana)Turkmen, 2004
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      N = 38 (96% “on”; 4% “of”)Service program (drop-in center)96.0Median age: 14 (7–18)SerologyHBV:

      HBsAg positive: 5%

      Anti-HBcAg: 32%

      Anti-HBsAg: 24%
      Kenya (Eldoret)Ayaya, 2001
      • Ayaya S.O.
      • Esamai F.O.
      Health problems of street children in Eldoret, Kenya.
      N = 191 (38 “on”; 47 “of”; 56 abandoned and in shelter; 50 schoolchildren with families)Street

      Shelter

      School
      NR14.3 (5–21)Physical examSTI: 2.6% diagnosed with an STI (HSV2, genital warts, genital ulcers)

      13.1% reported symptoms related to STI
      Nigeria (Ibadan)Olley, 2006
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      N = 169Street (snowball sample)89.318.4 (11–24)Self-reportSTI history (self-reported): any STI (21.7%); gonorrhea (14.2%); syphilis (5.3%); chancroid (.5%); herpes (1.7%)
      Nigeria (Ibadan)Owojae, 2009
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      N = 818 (580 “on”; 192 “of”)Street68.8(15–24)Self-reportPast year (self-reported): genital/vaginal discharge (7.7%); genital ulcer (4.2%)
      South Africa (Cape Town)Seager, 2010
      • Seager J.R.
      • Tamasane T.
      Health and well-being of the homeless in South African cities and towns.
      N = 305Street93(12–17)Self-reportPast year STI (self-reported): 5.5%
      Zimbabwe (Harare; Bulawayo; Mutare; Gweru; Kadoma)UNICEF, 2001

      UNICEF. 2001 ZIM: A study on street children in Zimbabwe. 2001. Available at: http://www.unicef.org/evaldatabase/index_14411.html. Accessed April 5, 2013.

      N = 260Street84.613 (0–18)Self-reportSTI history (self-reported): 14.3%

      Of-the-street children and children sleeping both at home and on the street more likely than on-the-street to report STI history (16.5% vs. 22.2% vs. 5.2%, respectively)
      HBc = hepatitis B core; HBs = hepatitis B surface; HBsAg = HBs antigen; HBV = hepatitis B virus; HSV2 = herpes simplex virus 2; IDU = intravenous drug user; IgM = immunoglobulin M; OR = odds ratio; SD = standard deviation; STI = sexually transmitted infection.
      a Unless otherwise specified.
      Table 3Substance use in street children in low- and middle-income countries
      Country (city)Author, yearSample sizeSourceGender (% male)Mean age in years (range)
      Unless otherwise specified.
      Results
      Argentina (Buenos Aires)Avila, 1996
      • Avila M.M.
      • Casanueva E.
      • Piccardo C.
      • et al.
      HIV-1 and Hepatitis B virus infections in adolescents lodged in security institutes of Buenos Aires.
      N = 1460Detention centers (“security institute”)81.016.6 (12–20)53% reported use of cocaine or morphine derivatives (IDU and non-IDU); 6.43% reported IDU
      Bolivia (La Paz)Huang, 2004
      • Huang C.C.
      • Barreda P.
      • Mendoza V.
      • et al.
      A comparative analysis of abandoned street children and formerly abandoned street children in La Paz, Bolivia.
      N = 159 (35 “on,” i.e., street children in orphanage; 124 “of,” i.e., abandoned on street)Street

      Orphanage
      69.014.4 (SD 2.9)Lifetime use of ETOH and inhalants (paint thinner) higher among abandoned children on the street than among street children in orphanage (58%/88% vs. 12%/41%, respectively)
      Brazil (Belo Horizonte)Campos, 1994
      • Campos R.
      • Raffaelli M.
      • Ude W.
      • et al.
      Social networks and daily activities of street youth in Belo Horizonte, Brazil. Street Youth Study Group.
      N = 379Street“On:” 79

      “Of:” 75
      Boys: 13.9 (9–18)

      Girls: 14.6 (9–18)
      Daily/weekly use of ETOH, drugs (inhalants, marijuana, ether, cough syrup, amphetamines, cocaine, hallucinogens), and injection drugs lower among on- than of-the-street children (18.2%/8.0%/.6%, vs. 40.0%/57.5%/10.6%, respectively)

      Current alcohol and drug use associated with older age among both on- and of-the-street children
      Brazil (Porto Alegre)de Carvalho, 2006
      • de Carvalho F.T.
      • Neiva-Silva L.
      • Ramos M.C.
      • et al.
      Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.
      N = 161Service programs (drop-in “service centers”)79.514 (Interquartile range 13, 17)Past year use: inhalants (31.7%); ETOH (83.8%); marijuana (34.2%); cocaine/crack (19.9%); overall illicit drug use (39.7%); IDU (1.2%)

      Inconsistent condom use associated with a history of inhalant use but not ETOH, marijuana, or cocaine

      History of illicit drug use independently associated with: older age, not currently in school, not in contact with family, been on the streets longer, spent more hours daily on the streets, history of sex, more sex partners, inconsistent/no condom use, STI in past year, having had an HIV test, perceiving self to be HIV+, having an HIV+ friend

      In multivariate analysis, illicit drug use associated with: older age, not being in contact with family, being on the street more hours/day, having had an HIV test
      Brazil (Porto Alegre)Forster, 1996
      • Forster L.M.K.
      • Tannhauser M.
      • Barros H.M.T.
      Drug use among street children in southern Brazil.
      N = 105 (48 “on,” i.e., living with family but not attending school; 31 “of,” i.e., not living with family and not attending school; 26 control, i.e., living with family and going to school)StreetTotal sample: 83

      Control: 77

      “On:” 81

      “Of:” 90
      “On:” 11.8 (6–18)

      “Of:” 12.1 (7–16)

      Control: 11.1 (8–18)
      Lifetime use of drugs (inhalants, marijuana, cocaine, medicines): 11% in control, 25% in on-the-street, 68% in of-the-street

      Of-the-street children significantly more likely than controls to report past year use of inhalants, marijuana, and medicines

      Of- significantly more likely than on-the-street youth to regularly use (5+ days in past week) inhalants and marijuana (42%/26%, vs. 12%/4%)
      Brazil (Belo Horizonte)Pinto, 1994
      • Pinto J.A.
      • Ruff A.J.
      • Paiva J.V.
      • et al.
      HIV risk behavior and medical status of underprivileged youths in Belo-Horizonte, Brazil.
      N = 394 (199 “on”; 195 “of”)Government shelterTotal sample: 71

      “On:” 62

      “Of:” 80
      13.3 (10–18)Of- more likely than on-the-street children to report drug use (77% vs. 29%, OR 7.8)

      Of-/on-the-street children reported use of: shoemaker's glue (81%/45%, respectively); paint thinner (79%/38%); marijuana (61%/38%); cough syrup (28%/7%); amphetamines (27%/12%); inhaled cocaine (21%/10%); injected cocaine (7%/5%)

      Of- initiated drug use earlier than on-the-street children (mean age at initiation 10.3 vs. 12.1)
      Brazil (Goiania)Porto, 1994
      • Porto S.O.B.
      • Cardoso D.D.P.
      • Queiroz D.A.O.
      • et al.
      Prevalence and risk factors for HBV infection among street youth in central Brazil.
      N = 496 (395 “on”; 101 “of”)Street

      Service programs (state institutions)
      Total sample: 93.3

      “On:” 76.2

      “Of:” 97.7
      “On:” 13.6 (SD 2.2)

      “Of:” 14.3 (SD 2.2)
      Of- more likely than on-the-street children to report oral or inhaled drug use (62.4% vs. 11.4%) and lifetime IDU (14.9% vs. .8%)
      Brazil (Fortaleza; Recife; Rio de Janeiro; Sao Paulo; Porto Alegre)Noto, 1997
      • Noto A.R.
      • Nappo S.A.
      • Galduroz J.C.F.
      • et al.
      Use of drugs among street children in Brazil.
      N = 565 (148 “on”; 414 “of”; 3 no response)Service programs (drop-in centers)72.66–17 (86.9% ≥12)Lifetime/past month/daily use: any drug (74.5%/51.7%/27.1%); solvents (67.6%/41.2%/20.9%); marijuana (53.1%/33.5%/12.0%); cocaine (21.2%/10.4%/2.3%); anticholinergics (15.2%/10.3%/5.5%); anxiolytics (16.8%/10.8%/6.0%); benzydamine (4.0%/1.2%/.2%)

      Lifetime IDU: 3.4%
      Brazil (Belo Horizonte)Raffaelli, 1995
      • Raffaelli M.
      • Siqueira E.
      • Paynemerritt A.
      • et al.
      HIV-related knowledge and risk behaviors of street youth in Belo-Horizonte, Brazil.
      N = 379Street77.0Boys: 13.9

      Girls: 14.6
      Lifetime reported: IDU (5.8%); shared needles (2.4%)
      Costa Rica (Heredia; San Jose; Puntarenas; Limon)Obando, 2004
      • Obando P.
      • Kliewer W.
      • Murrelle L.
      • et al.
      The comorbidity of substance abuse and depressive symptoms in Costa Rican adolescents.
      N = 5,268 (83 street children from San Jose; 218 youth in treatment for substance abuse; 4,967 high school students)Street

      Service program (drug treatment)

      School
      71.0Street children: 15.34

      Drug treatment: 15.89

      Schoolchildren: 15.27
      Street children's reported lifetime prevalence of drug use (inhalants, marijuana, tobacco, cocaine, crack, “basuco,” ecstasy) and ETOH/drug-related problems higher than schoolchildren and lower than children in drug treatment

      Depressive symptoms higher among street children and children in treatment than schoolchildren. Depressive symptoms most strongly associated with substance use among female street children
      Honduras (Tegucigalpa)Wittig, 1997
      • Wittig M.C.W.
      • Wright J.D.
      • Kaminsky D.C.
      Substance use among street children in Honduras.
      N = 1,244 (1,084 “on”; 160 “of”)StreetTotal sample: 58

      53 “on”; 95 “of”
      “On:” 10

      “Of:” 13
      Of- more likely than on-the-street children to report use of inhalants (toluene) (53.2% vs. .8%); ETOH (43.1% vs. 3.9%); cigarettes (56.7% vs. 4.9%)

      Among of-the-street children, inhalant users more likely than non-inhalant users to: report use of ETOH (76.5% vs. 5.6%), tobacco (90.2% vs. 16.9%), and marijuana (29.3% vs. 1.4%); be older (mean age 14 vs. 12); sleep on the street (82.9% vs. 33%); have lived on the street longer (42.3 vs. 22.9 months); be in “fair” or “poor” physical health (27.8% vs. 17.8%), nutritional status (28.9% vs. 20.5%), and mental health (28.9% vs. 5.5%); report never receiving medical care (12.5% vs. 1.6%); have been treated for an STI (78.2% vs. 54.5%)
      Ukraine (Odessa, Kiev, Donetsk)Hillis, 2011
      • Hillis S.D.
      • Zapata L.
      • Robbins C.L.
      • et al.
      HIV seroprevalence among orphaned and homeless youth: No place like home.
      N = 929 (182 housed non-orphan; 343 homeless non-orphan; 104 housed orphan; 300 homeless orphan)Street (time-location sampling)76(15–24)ETOH ≥10 days in the past month: 6% neither homeless nor orphan; 9.6% either homeless or orphan; 15.3% both homeless and orphan

      Lifetime use (either/neither/both): any drug (61%/70.7%/84.3); IDU (15.4%/31.8%/47.7%); needle sharing (7.7%/21.7%/31.7%)
      Ukraine (Kyiv)Kerfoot, 2007
      • Kerfoot M.
      • Koshyl V.
      • Roganov O.
      • et al.
      The health and well-being of neglected, abused and exploited children: The Kyiv Street Children Project.
      N = 97 (29 “on,” i.e., live permanently at home; 57 “of,” (i.e., sleep away from home, with 23 youth partially and 34 fully disconnected from family)Service programs (shelter facilities and outreach/drop-in center)74.212.8 (6–17)63% reported substance use (ETOH, inhalants, and/or other drugs)

      24% used ETOH only; 15% inhalants only; 12% ETOH and inhalants; 3% ETOH and other drugs; 9% ETOH, inhalants, and other drugs

      Of- more likely than on-the-street children to report substance abuse (91% children connected to family but not sleeping at home vs. 73% children fully disconnected from family vs. 35% children sleeping at home)
      Ukraine (Kyiv; Odessa; Donetsk)Zapata, 2011
      • Zapata L.B.
      • Kissin D.M.
      • Robbins C.L.
      • et al.
      Multi-city assessment of lifetime pregnancy involvement among street youth, Ukraine.
      N = 929 (182 housed non-orphan; 343 homeless non-orphan; 104 housed orphan; 300 homeless orphan)Street (time-location sampling)76(15–24)Among the full sample, males more likely than females to report lifetime experience of: any drug use (76.9% vs. 61.4%); IDU (36.4% vs. 25.1); needle sharing (24.2% vs. 15.7%)
      Russia (St. Petersburg)Kissin, 2007
      • Kissin D.M.
      • Zapata L.
      • Yorick R.
      • et al.
      HIV seroprevalence in street youth, St Petersburg, Russia.
      N = 313Street locations randomly selected from sampling frame63.3(15–17)Lifetime use of any drug: 84.7%

      ETOH consumption several times or more/week: 72.2%

      Lifetime/current use: inhalants (55.2%/40.1%); marijuana (75.6%/29.6%); Stadol (44.2%/19.9%); heroin (34.4%/23.3%); ephedrine (19.8%/7.4%); IDU (50.7%/32.9%); needle sharing (33.3%/18.9%)

      HIV-positive youth significantly more likely to report lifetime substance use, more frequent alcohol consumption, obtaining drugs from a pharmacy, lifetime/current inhalant, heroin, and Stadol use, lifetime/current IDU, needle sharing
      Nepal (Dharan)Thapa, 2009
      • Thapa K.
      • Ghatane S.
      • Rimal S.
      Health problems among the street children of Dharan municipality.
      N = 48 (37 “on”; 11 “of”)NR95.8Most (68.8%)

      11–15
      Reported use of: smoking tobacco (87.5%); chewing tobacco (37.5%); ETOH (50%); glue (dendrite) (72.9%)
      India (Kolkata)Bal, 2010
      • Bal B.
      • Mitra R.
      • Mallick A.H.
      • et al.
      Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India.
      N = 554Street65Median age 13 (50% between 11 and 15)52% reported substance use; 22% reported tobacco use only: 30% reported “regular drug use”

      Among substance users, children reported using: dendrite (43%); ETOH (16%); marijuana (25%); “brown sugar” (11%); heroin (3%); N-10 (2%) 89.7% initiated drug use by the age of 15

      Substance abuse associated with older age, male, orphan, no contact with family, sleeping in public places
      India (Delhi)Khurana, 2004
      • Khurana S.
      • Sharma N.
      • Jena S.
      • et al.
      Mental health status of runaway adolescents.
      N = 150Shelter (“child observation home”)NR(10–16)Lifetime use of: any drug (55.3%); inhalants (2.66%); tobacco (49.6%); marijuana (.67%)
      India (Kolkata)Mondal, 2011
      • Mondal N.K.
      • Ghosh S.
      • Ray M.R.
      Micronucleus formation and DNA damage in buccal epithelial cells of Indian street boys addicted to gasp ‘Golden glue’.
      N = 352 (302 tobacco and/or glue-using street boys; 50 schoolchildren controls)Street

      Schools
      100(8–16)Current inhalant use (2–8 times daily): 51.3%

      Glue sniffing by street children was correlated with chromosomal and DNA damage in buccal, epithelial cells, controlling for tobacco exposure and loss of appetite
      India (Delhi)Pagare, 2004
      • Pagare D.
      • Meena G.
      • Singh M.
      • et al.
      Risk factors of substance use among street children from Delhi.
      N = 115Shelter (“child observation home”)100(6–16)Lifetime use of: any drug (57.4%); inhalants (glue, petrol, thinner, spirit) (24.3%); ETOH (21.8%); nicotine (44.5%); marijuana (26.4%)

      70% reported knowledge of harmful effects of drugs

      Substance use associated with maltreatment at home
      India (Bangalore)Ramakrishna, 2007

      Ramakrishna J, Karott M, Murthy R. Experiences of sexual coercion among street boys in Bangalore, India. In: Bott S, Jejeebhoy S, Shah I, et al, eds. Towards adulthood: Exploring the sexual and reproductive health of adolescents in South Asia. Geneva, Switzerland: 2003. p. 95–98.

      N = 121Service program (outreach)10016 (9–23)Half reported inhalant use (typewriter correction fluid); 46% used ETOH
      India (Delhi)Seth 2005
      • Seth R.
      • Kotwal A.
      • Ganguly K.K.
      Street and working children of Delhi, India, misusing toluene: An ethnographic exploration.
      N = 45 (15 “on”; 30 “of,” i.e., living on street or shelter)Service programs (drop-in centers) (snowball sample)NRMedian age 13 (9–18)Inclusion criteria included current inhalant use. Inhalant use frequency ranged from twice ever to multiple times per day

      Most reported poly-substance use (including ETOH, tobacco, marijuana, and heroin)

      Median reported age of drug initiation: 10 (6–14)

      84.4% experienced withdrawal symptoms

      Most recognized that inhalant use had harmful physical/mental effects
      India (Delhi)Tiwari, 2006
      • Tiwari P.
      Life on streets.
      N = 400Shelter (“child observation home”)100(6–16)Reported use of: any substance (50.5%); ETOH (16.7%); smoked tobacco (26.0%); chewed tobacco (8.5%); drugs (marijuana, “bhang,” “charas,” IDU) (8.25%); poly-substance use (32.0%)
      Iran (Tehran)Fallah, 2008
      • Fallah F.
      • Karimi A.
      • Eslami G.
      • et al.
      The homeless youth and their exposure to hepatitis B and hepatitis C among in Tehran, Iran.
      N = 203Government shelter (“welfare center”)96.6(7–18)13% reported current tobacco smoking. Of these, 3% heavy smokers (10+/day); 1% medium (1–9/day); 9% rare (1–2/week)
      Pakistan (Lahore)Sherman, 2005
      • Sherman S.S.
      • Plitt S.
      • ul Hassan S.
      • et al.
      Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan.
      N = 347Service program (outreach)96.013Lifetime drug use: 83.0%

      Past month use: any drug (67.1%); inhalants (73.4%); hashish (80.7%); “bhang” (46.4%), heroin (sniff/smoke) (8.6%); heroin (IDU) (3.9%)

      Current drug users more likely than former/never-users to: be male (99.1% vs. 98.2%/81.4%, respectively); be older (14 vs. 13/12); sleep on the streets rather than at home (82.3% vs. 67.9%/66.1%); have lived on the streets longer (30 vs. 12/6 mos.); have had sex (62.7% vs. 45.5%/18.6%); want to go home (68.0% vs. 62.3%/41.7%)

      In multivariate analyses, current drug use associated with older age, wanting to go home, exchange sex, self-cutting
      Pakistan (Lahore)Towe, 2009
      • Towe V.L.
      • ul Hasan S.
      • Zafar S.T.
      • et al.
      Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.
      N = 565Service program (outreach)100(5–19)Children who engaged in exchange sex more likely than those who did not to report lifetime use of: any drug (93.0% vs. 77.4%); inhalants (61.5% vs. 35.4%); tobacco (98.1% vs. 97.4%); hashish (67.7% vs. 48.2%); heroin (sniff/smoke) (9.6% vs. .9%); IDU (3.1% vs. .3%)

      29.7% had exchanged sex for drugs in their lifetime
      Philippines (Manila)Merrill, 2010
      • Merrill R.M.
      • Njord L.
      • Njord R.
      • et al.
      The effect of family influence on indicators associated with street life among Filipino street children.
      N = 624 (441 “on”; 183 “of”)Service program54(8–17)Lifetime use: legal substances (tobacco, ETOH, inhalants) (44%); illicit substances (marijuana, amphetamines, ecstasy) (14%)

      Of-the-street children reported higher rates of drug use than those living with family (licit drug use, 73%–87% vs. 29%; illicit drug use, 22%–40% vs. 6%).
      Philippines (Manila)Njord, 2010
      • Njord L.
      • Merrill R.M.
      • Njord R.
      • et al.
      Drug use among street children and non—street children in the Philippines.
      N = 839 (170 “on”; 141 “of”; 528 non-street)Service programs; SchoolsTotal sample: 51.3

      “On:” 48.5

      “Of:” 70.7

      Non-street: 47
      (13–17)Of- more likely than on-the-street and non-street children to report using: tobacco (78.7% vs. 34.3% vs. 33.3%); ETOH (73.8% vs. 45.0% vs. 48.8%); inhalants (61.7% vs. 15.2% vs. 1.7%); illegal drugs (methamphetamines, marijuana, ecstasy) (40.4% vs. 15.2% vs. 4.7%)

      On-the-street more likely than non-street children to use inhalants and illegal drugs
      Turkey (Istanbul)Ogel, 2006
      • Ogel K.
      • Taner S.
      • Tosun M.
      • et al.
      Juvenile offences among hospitalized adolescent inhalant users in Istanbul: A comparison regarding place of residence.
      N = 200 (51.2% of-the-street; 48.8% children living with family)Service program (drug treatment facility)100Total sample: 15.6 (±2.0)Inclusion criteria included daily inhalant use in past 6 months

      Among total sample, children reported use of: inhalants (glue/thinner, 91.0%/74.0%); ETOH (85.0%); tobacco (99.5%); marijuana (56.5%); flunitrazepam (6.5%); clonazepam (1.5%); opioids (2.0%)
      Turkey (Istanbul)Olgar, 2008
      • Olgar S.
      • Oktem F.
      • Dindar A.
      • et al.
      Volatile solvent abuse caused glomerulopathy and tubulopathy in street children.
      N = 97 (48 street-based children; 49 healthy controls living with family)Government shelter

      Case control (source unspecified)
      100Street: 16.24

      Control: 16.96
      87.5% of street children reported lifetime inhalant use

      Street children reported use of: tobacco (“almost all”); morphine/morphine derivatives (27.1%); ecstasy (29.2%); hashish (14.6%)

      Street children initiated thinner use earlier (12.6 ± 2.6 vs. 12.93 ± 2) and had used for longer (4.56 years ± 2.6 vs. 3.4 years ± 2) than non-street children

      Significantly increased urinary excretion of protein, N-acetyl-beta-D-glucosamininidase (NAG) and of electrolytes among street children relative to noninhalant using housed controls suggest glomerular damage and proximal and distal tubular dysfunction
      Turkey (Istanbul)Olgar, 2008
      • Olgar S.
      • Dindar A.
      • Ertugrul T.
      • et al.
      Electrocardiographic and echocardiographic findings in street children known to be substance abusers.
      N = 114 (53 street-based children; 61 healthy controls living with family)Government shelter

      Case control (source unspecified)
      100Street: 16.24

      Control: 16.96
      Street children reported lifetime use of: thinner (73.6%); glue (75.5%); ETOH (60.4%); tobacco (100%); hashish (79.2%); ecstasy (37.7%); antiemetics (13.2%)

      Street children reported mean ages of initiation to substances ranging from 9.68 (tobacco) to 14.72 (cocaine)

      ECG abnormalities found only in street children. PR, QRS, and QT intervals significantly longer among street children than among housed controls. Echocardiographic findings also significantly different from housed controls
      Turkey (Adana)Turkmen, 2004
      • Turkmen M.
      • Okyay P.
      • Ata O.
      • et al.
      A descriptive study on street children living in a southern city of Turkey.
      N = 52 (89% “on”; 11% “of”)Service program (drop-in center)96.0Median age 14 (7–18)46% reported use of tobacco (15% more than 10 per day; 4% 1–9 per day; 27% less than daily)

      Lifetime substance use (smelling adhesives, ETOH, cigarettes, marijuana, heroin): 50%

      2% reported use of smelling adhesives; 40% reported “unknown” substance use
      Egypt (Assiut)Elkoussi, 2011
      • Elkoussi A.
      • Bakheet S.
      Volatile substance misuse among street children in upper Egypt.
      N = 120Stratified random sample97.514.63 (10–18)Daily use of: inhalants (90.8%); any other substances (75%); prescription drugs (45.8%); marijuana (25.0%); hashish (20.8%); opium (7.5%)

      Study further reports toxicological effects of glue on rats
      Egypt (Alexandria)Hosny, 2007
      • Hosny G.
      • Moloukhia T.M.
      • Abd Elsalam G.
      • et al.
      Environmental behavioural modification programme for street children in Alexandria, Egypt.
      N = 35 (8% “on”; 92% “of”)Service program (shelter)100(7–15)All children reported tobacco use

      Children reported using unspecified substances: “always,” 43%; “sometimes,” 57%; “never,” 0%
      Egypt (Cairo, Alexandria)Nada, 2010
      • Nada K.H.
      • Suliman E.D.A.
      Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt.
      N = 857Street (time-location sampling)84.8(12–17)Lifetime drug use: 62%

      Current use: drugs (51%); ETOH (35%); IDU (3%)

      Current drug use higher among males than females; current ETOH use higher among older youth and males
      Egypt (Alexandria)Salem, 2002
      • Salem E.M.
      • El-Latif F.A.
      Sociodemographic characteristics of street children in Alexandria.
      N = 100 (6% “on”; 94% "of”)Street, service program (rehabilitation program)10013.7 (7–16)All children reported substance use, including: inhalants (glue/solvents) (88%/37%); ETOH (6%); tobacco (75%); marijuana (bango) (24%); unspecified “drug addiction” (40%); heroin (1%); poly-substance use (100%)
      Ethiopia (Addis Ababa)Lalor, 1999
      • Lalor K.J.
      Street children: A comparative perspective.
      N = 160StreetNRNRLifetime/weekly/daily use of: ETOH (16.4%/2.4%/1.6%); tobacco (5.5%/.1%/3.2%); khat (7.3%/.4%/.4%); benzene (2.5%/.1%/.2%); other (7.9%/.4%/.2%)
      Kenya (Eldoret)Ayaya, 2001
      • Ayaya S.O.
      • Esamai F.O.
      Health problems of street children in Eldoret, Kenya.
      N = 191 (38 “on”; 47 “of”; 56 abandoned and in shelter; 50 schoolchildren with families)Street

      Service program (shelter)

      School
      NRTotal sample: 14.03 (5–21)The rate of substance use for the total sample was 545 per 1,000 children; none of the schoolchildren reported substance use

      Reported use of: inhalants (glue) (31.2%); ETOH (18.3%); tobacco (37.6%); marijuana (8.3%); cocaine (4.6%)
      Nigeria (Ibadan)Morakinyo, 2003
      • Morakinyo J.
      • Odejide A.O.
      A community based study of patterns of psychoactive substance use among street children in a local government area of Nigeria.
      N = 180Street96.7014.6 (8–18)Lifetime/past month use of: any substance (45%/42.2%); inhalants (.6%/0%); ETOH (30.6%/23.9%); kola nut (16.7%/13.9%); tobacco (14.4%/10.0%); marijuana (10.0%/7.8%); stimulants (15.6%/6.1%); hypnosedatives (3.3%/3.3%); “paw-paw” (1.1%/1.1%)

      No reported lifetime use of heroin, cocaine, hallucinogens, or IDU

      No reported current or lifetime substance use among females

      51.9% aged 10–13 at initiation of substance use

      Introduced to substances by friends (39.9%) and family members (33.3%)

      Time on the street associated with current substance use
      Nigeria (Ibadan)Olley, 2006
      • Olley B.O.
      Social and health behaviors in youth of the streets of Ibadan, Nigeria.
      N = 169Street (snowball sample)89.318.4 (11–24)Lifetime: ETOH abuse (69.0%); tobacco use (50.2%); “other” unspecified drug abuse (14.0%)

      ETOH, tobacco, and “other” drug dependence associated with older age (19–24 vs. 11–18)
      Nigeria (Ibadan)Owoaje, 2009
      • Owoaje E.
      • Uchendu O.
      Sexual risk behaviour of street youths in southwest Nigeria.
      N = 818 (580 “on”, 192 “of”)Street68.8(15–24)Past month use: ETOH (28.6%); amphetamine-containing drugs (14.9%); marijuana (2.0%); IDU (<2%)
      South Africa (Cape Town)Seager, 2010
      • Seager J.R.
      • Tamasane T.
      Health and well-being of the homeless in South African cities and towns.
      N = 305Street93(12–17)Lifetime use: any drug (37%)

      Past 3 months' use: any drug (37%); glue/thinners/petrol (25.9%); mandrax (4.9%); marijuana (23.3%); heroin (2.6%); crystal methamphetamine (2.6%); ecstasy, (2.0%); “other” (4.6%)

      ETOH 2+ times per week (3.7%). Drinkers reported 6+ drinks on one occasion: never, 30.9%; less than monthly, 14.5%; monthly, 23.6%; weekly, 23.6%; daily/almost daily, 1.8%
      Sudan (Khartoum)Kudrati, 2008
      • Kudrati M.
      • Plummer M.L.
      • Yousif N.D.
      Children of the Sug: A study of the daily lives of street children in Khartoum, Sudan, with intervention recommendations.
      N = 432Street91.9Estimated ages:

      <10, 13%–14%

      11–14, 37%–42%

      15–18, 47%–48%
      Lifetime (male/female) use: glue (70%/69%); ETOH (42%/40%).

      Past day (male/female) use: glue (63%/68%); ETOH (31%/21%); tobacco (63%/63%)
      ECG = electrocardiogram; ETOH = ethanol; IDU = intravenous drug use; STI = sexually transmitted infection.
      a Unless otherwise specified.

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