Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street‐connected children and young people: a systematic review

This review assessed the effectiveness of interventions for improving outcomes among street‐connected children and young people, and for reducing some important health‐related risks; and to improve access to and integration into society, education, and employment opportunities. Eligible study designs compare outcomes from interventions for street‐connected children and young people aimed at reintegration, education, employment, improving health and/or harm reduction, and provision of shelter, versus a comparison group (e.g. shelter/drop‐in service as usual). The review identified 13 studies evaluating 19 interventions. All studies were conducted in the USA except one (South Korea). The outcome for integration was not measured in included studies. The same was the case for education and employment related outcomes – none of the included studies measured literacy, numeracy, or participation in education or skills‐based employment. Several studies measured health‐related outcomes. Five studies investigate the effect of interventions to encourage safe or reduced sexual activity (e.g. numbers of partners, frequency of sex, HIV knowledge, unprotected sex, condom use and rates of abstinence). The results are mixed, lacking enough evidence to support any of the interventions. Eight studies report outcomes of interventions promoting safe or reduced substance use. The outcomes used a variety of measures in different studies at various times making it difficult to get a clear overview. The overall effect was mixed; some studies report positive effect and the others reported negative or no effect. Three studies investigate the effect of family therapy on substance abuse and report improvements in some of the measures. Eight studies investigate the effect of therapeutic interventions to improve mental health (including self‐esteem and depression) in street‐connected kids. In general, there is no significant improvement in the intervention group compared to the control group. In some instances, both groups improved from the baseline. Finally, two studies investigate the effect of family‐based approaches on family functioning. No differences were found between intervention and control conditions on most of the outcome measures used. Plain language summary Lack of evidence on the effectiveness of interventions to reintegrate street‐connected children There are a range of interventions to improve the integration and well‐being of street‐connected children, yet no studies measure integration, education or employment outcomes. There appears to be no effect on and mixed evidence for mental health. There may be reductions in substance abuse. What is this review about? Millions of street‐connected children throughout the world are at risk of exploitation, violence, substance abuse, and health problems, and are not receiving skills‐based education. Interventions to promote access to education, healthy and settled lifestyles, and reduction of risks are intended to give this group a better chance in life and prevent marginalization from society. What is the aim of this review? This review assessed the effectiveness of interventions for improving outcomes among street‐connected children and young people, and for reducing some important health‐related risks; and to improve access to and integration into society, education, and employment opportunities. This review investigates the effects of interventions for street‐connected children to promote integration to the society, skills‐based education, prospects of employment and health risk reduction. What are the main findings of this review? What studies are included? Eligible study designs compare outcomes from interventions for street‐connected children and young people aimed at reintegration, education, employment, improving health and/or harm reduction, and provision of shelter, versus a comparison group (e.g. shelter/drop‐in service as usual). The review identified 13 studies evaluating 19 interventions. All studies were conducted in the USA except one (South Korea). The outcome for integration was not measured in included studies. The same was the case for education and employment related outcomes – none of the included studies measured literacy, numeracy, or participation in education or skills‐based employment. Several studies measured health‐related outcomes. Five studies investigate the effect of interventions to encourage safe or reduced sexual activity (e.g. numbers of partners, frequency of sex, HIV knowledge, unprotected sex, condom use and rates of abstinence). The results are mixed, lacking enough evidence to support any of the interventions. Eight studies report outcomes of interventions promoting safe or reduced substance use. The outcomes used a variety of measures in different studies at various times making it difficult to get a clear overview. The overall effect was mixed; some studies report positive effect and the others reported negative or no effect. Three studies investigate the effect of family therapy on substance abuse and report improvements in some of the measures. Eight studies investigate the effect of therapeutic interventions to improve mental health (including self‐esteem and depression) in street‐connected kids. In general, there is no significant improvement in the intervention group compared to the control group. In some instances, both groups improved from the baseline. Finally, two studies investigate the effect of family‐based approaches on family functioning. No differences were found between intervention and control conditions on most of the outcome measures used. What was the quality of the evidence? The quality of evidence was from low (i.e. for risk reduction in sexual activity and family therapy) to moderate (i.e. mental health improvement, harm reduction in substance abuse). What do the findings of this review mean? There is a dearth of evidence from controlled trials on interventions to improve integration of street‐connected children and young adults into society and providing skills‐based education. The evidence from health interventions aimed at engaging in safe sexual practices, and at improving mental health vary widely and are inconclusive as to their effectiveness. Some of the interventions aimed at reducing the risk of substance abuse may be effective. Further research in this area will be useful in understanding the effectiveness of these approaches and validating the effect of some of the interventions that are supported by moderate evidence. How up‐to‐date is this review? The review authors searched for relevant studies until April 2015. This Campbell review was published in 2016. Abstract Background Millions of street‐connected children and young people worldwide live or work in street environments. They are vulnerable to many risks, whether or not they remain connected to families of origin, and despite many strengths and resiliencies, they are excluded from mainstream social structures and opportunities. Objectives Primary research objectives To evaluate and summarise the effectiveness of interventions for street‐connected children and young people that aim to: • promote inclusion and reintegration; • increase literacy and numeracy; • facilitate access to education and employment; • promote mental health, including self esteem; • reduce harms associated with early sexual activity and substance misuse. Secondary research objectives • To explore whether effects of interventions differ within and between populations, and whether an equity gradient influences these effects, by extrapolating from all findings relevance for low‐ and middle‐income countries (LMICs) (Peters 2004). • To describe other health, educational, psychosocial and behavioural effects, when appropriate outcomes are reported. • To explore the influence of context in design, delivery and outcomes of interventions. • To explore the relationship between numbers of components and duration and effects of interventions. • To highlight implications of these findings for further research and research methods to improve evidence in relation to the primary research objective. • To consider adverse or unintended outcomes. Search methods We searched the following bibliographic databases, searched for the original review, from inception to 2012, and various relevant non‐governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and Pre‐MEDLINE; EMBASE and EMBASE Classic; Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycINFO; Education Resource Information Center (ERIC); Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; Latin American Caribbean Health Sciences Literature (LILACS); System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and International Monetary Fund (IMF) Libraries; British Library for Development Studies (BLDS); Google and Google Scholar. We updated the search in April 2015 for the review update, using the same methods. Selection criteria This review includes data from harm reduction or reintegration intervention studies that used a comparison group study design; all were randomised or quasi‐randomised studies. Studies were included if they evaluated interventions provided for street‐connected children and young people, from birth to 24 years, in all contexts. Data collection and analysis Two review authors independently extracted data and assessed risk of bias and other factors presented in the Discussion and Summary quality assessment (Grades of Recommendation, Assessment, Development and Evaluation (GRADE)). We extracted data on intervention delivery, context, process factors, equity and outcomes, and grouped outcomes into psychosocial outcomes, risky sexual behaviours or substance use. We conducted meta‐analyses for outcomes where the outcome measures were sufficiently similar. We evaluated other outcomes narratively. Main results We included 13 studies evaluating 19 interventions from high‐income countries (HICs). At update stage (from our 2015 search), one previously included study was removed and three new studies added (since our 2012 search). We found no sufficiently robust evaluations conducted in low‐ and middle‐income countries (LMICs). Study quality overall was low and measurements used by studies variable. Participants were classified as drop‐in and shelter‐based. No studies measured the primary outcome of reintegration and none reported on adverse effects. We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexually risky behaviours . Interventions evaluated consisted of time‐limited therapeutically based programmes that proved no more effective than standard shelter or drop‐in services and other control interventions used for most outcomes in most studies. Favourable changes from baseline were reported for outcomes for most participants following therapy interventions and standard services. We noted considerable heterogeneity between studies and inconsistent reporting of equity data. No studies measured the primary outcome of reintegration or reported on adverse effects. Authors' conclusions Analysis revealed no consistently significant benefit for focused therapeutic interventions compared with standard services such as drop‐in centres, case management and other comparable interventions for street‐connected children and young people. Commonly available services, however, were not rigorously evaluated. Robust evaluation of interventions, including comparison with no intervention, would establish a more reliable evidence base to inform service implementation. More robust research is needed in LMICs to examine interventions for street‐connected children and young people with different backgrounds and service needs.