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Enabling structural resilience of street-involved children and youth in Kenya: reintegration outcomes and the Flourishing Community model

PMCID: PMC10482225

PMID: 37680240

Abstract

Introduction Millions of children and youth live on city streets across the globe, vulnerable to substance use, abuse, material and structural neglect. Structural resilience, the re-establishment of access to structural goods within a society such as housing, education, and healthcare following some interruption, provides an orientation for research and interventional efforts with street-involved children and youth (SICY). Further, a structural resilience framework supports organizing interactions between levels and sectors of a socio-ecology. Methods Following the expressed interests of Kenyan SICY, and consistent with emerging policy interests at national and global levels, we assess reintegration trajectories of Kenyan SICY ( n = 227) participating in a new program intervention and model. The intervention combines two coordinated, parallel programs – one focused on the rescue, rehabilitation, reintegration and resocialization of SICY, and the other focused on empowering families and communities to provide better care for children and youth who are reintegrating from life on the streets to the broader community. Data were collected and analyzed from multiple stages across SICY involvement with the intervention. Results We found 79% of SICY participants reintegrated with the broader community, and 50% reintegrated with families of origin and returned to school. Twenty-five percent of participants reintegrated to a boarding school, polytechnical school, or began a business. Probability of reintegrating successfully was significantly improved among participants whose families participated in the family- and community-oriented program, who were younger, with less street-exposure, expressed more personal interests, and desired to reintegrate with family. Discussion To our knowledge, these are the first quantitative data published of successful reintegration of SICY to the broader, non-institutionalized community in any low- or middle-income country. Future research should (1) identify factors across socio-ecological levels and sectors contributing to health and developmental outcomes of reintegrated children and youth, (2) mechanisms to support SICY for whom the interventional strategy did not work, (3) methods to prevent street-migration by children and youth, and (4) system development to coordinate follow-up and relevant investment by institutions, organizations and community leaders to continue reintegration work.

Full Text

The United Nations Children’s Fund has previously published estimates that tens of millions of children live on city streets globally, separated from adult caregivers (UNICEF, 2005). A notoriously difficult population to enumerate, street-involved children and youth (SICY) are vulnerable to multiple forms of abuse on the streets, human trafficking, substance misuse, and failure to thrive (Mathur et al., 2009; Nada and El Daw, 2010; Malindi and MacHenjedze, 2012; Pullum et al., 2012; Embleton et al., 2013; Aransiola and Zarowsky, 2014).
Published estimates of the number of Kenyan SICY range from 46,639 to 300,000 (Sorber et al., 2014; Street Families Rehabilitation Trust Fund, 2018). The study producing the lower estimate, released by the Kenyan Ministry of Labour and Social Protection in 2018, faced multiple limitations undermining its reliability – such as distrust between enumerators and children, budget over-runs due to the need for increased security, language barriers between interviewers and children, and criminal cartels who interfered with the underfunded study (Street Families Rehabilitation Trust Fund, 2018). The higher estimate is regularly cited as authoritative in peer-reviewed literature; however, it was released as a report from a news agency in 2007, citing the estimates of experts without peer-reviewed analysis or methodological transparency (IRIN, 2007).
The phenomenon of children living on the street is a multi-level problem, understood best through Bronfenbrenner’s socio-ecological model. Figure 1 displays a non-exhaustive compilation of known factors associated with street-migration among children. Across time (chronosystem), industrialization and dominant global economic development models contribute to urbanization (Patil, 2014). According to United Nations data, the percentage of population living in urban areas in Eastern Africa increased fourfold between 1950 and 2020 – equal to the growth in Kenya (United Nations, Department of Economic and Social Affairs, Population Division [UNDESAPD], 2018). Across sub-Saharan Africa, including in Kenya, urbanization followed railways placed by colonizing European country governments – a trajectory that continued after railways became less utilized (Jedwab and Moradi, 2016; Jedwab et al., 2017a). At the beginning of the 20th century, sub-Saharan Africa contained only about 50 cities with 10,000 or more inhabitants. By 2010, the number of cities with at least 10,000 inhabitants grew to almost 3,000 (Jedwab et al., 2017b).
The emergence of cities, new economic opportunities and political economies influence macro-, exo-, meso-, and micro-systems impacting risk of street migration among children. One example of the impact urbanization and new migration routes have on communities and families is the early geographic spread of HIV – which followed economic routes created by colonizing forces (Faria et al., 2014). While it is difficult to trace the numerical rise of SICY across colonizer-induced dynamics, urbanization is a necessary element for children to sleep on city streets. Further exacerbating disruptive inequities due to forced participation in the globalized economy, the structural adjustment programs inspired by the Washington Consensus and championed by the great powers in the late 1980s exacerbated the relative standing of rural communities, women and children with respect to health outcomes, income, education, and social cohesion (Ahmed and Lipton, 1997; Craig and Porter, 2005; Thomson et al., 2017; Forster et al., 2020).
There is a dire need for evidence-informed programmatic and policy interventions to support the wellbeing and self-determination of SICY. In 2010, the United Nations General Assembly adopted a resolution calling for member states to shift from placement of children in long-term care facilities toward reintegration of separated children (United Nations General Assembly [UNGA], 2010). In 2012, the United Nations High Commissioner for Human Rights published a report on “the protection and promotion of the rights of children working and/or living on the street.” The report recognized governments as primary duty-bearers to meet the obligation of having the rights of children respected and fulfilled. The UN High Commission report required States to present legislation to mandate municipal policies and resource-coordinated interventions for SICY (Office of the High Commissioner for Human Rights [OHCHR], 2012). The United Nations Convention on the Rights of the Child issued a general comment in 2017 aiming to provide comprehensive, authoritative guidance to States toward a holistic, rights-based approach to prevent street-migration of children and ensure a continuum of care for SICY to develop their fullest potential (UN Committee on the Rights of the Child, 2017).
Kenya is one of many low- and middle-income countries working to address the social and health challenges confronting SICY. In 2022, the national government of Kenya released its National Care Reform Strategy for Children endorsing reforms to (1) prevent family separation and promote family strengthening, (2) support alternative care and transition away from institutional care, and (3) trace, reintegrate and transition to family- and community-based care (Kenya Ministry of Labour and Social Protection, 2022). Kenya’s national plan for care reform includes efforts to defund institutionalization of children, a plan that is supported by good evidence (e.g., Lionetti et al., 2015; Lyneham and Facchini, 2019). However, due to the paucity of evidence, neither the UN resolution nor the Kenya Care Reform strategy provides evidence to support the perspective that SICY can be successfully reintegrated with families of origin or foster families. A 2016 global review of literature presenting interventional effectiveness of programs designed to reintegrate SICY found no studies measuring inclusion and reintegration of SICY anywhere in the world, and no studies exploring interventional outcomes of programs in low- or middle-income countries (Coren et al., 2016). Evidence-informed strategies are required to ensure that children living on the streets are not simply placed back in abusive or unstable families they fled when they initially migrated to the streets.
A team of public health researchers, community leaders and social workers, our own work with SICY began in 2012 in response to local concerns about the growing number of children who were migrating to the streets of Meru County, Kenya (Seidel et al., 2017, 2018). Figure 2 illustrates the heterogeneity of households reporting street-migration of children between communities within three sub-counties in Meru County, stratified by HIV-status. Statistically significant variation in probability of reporting a child lives on the street differs by HIV-status of adults in the household and village location (Goodman et al., 2016). Mixed methods research reveals multiple community- and family-level predictors of street-migration – including maternal childhood adversities, maternal years of schooling, family cohesion, financial resources, parental mental health, substance use, and maternal social support (Goodman et al., 2017). Learning disabilities appear at higher rates among street-involved children than within the broader population, indicating child-level differences that may contribute to street-migration risk (Ward and Seager, 2010).
Variation in street-migration by village and parental HIV status within three Kenyan sub-counties. Data from Goodman et al. (2017).
Despite the complex socioecology of street-migration among children, many SICY experience high rates of stigma related to life on the streets (Rivenbark et al., 2018; Gayapersad et al., 2020). Often interventions to assist vulnerable children and promote child resilience are not adequately informed by a socio-ecological model and may risk reinforcing an individualistic view of children’s resilience capacities (van Breda and Theron, 2018). An individualistic focus is particularly unhelpful, and blames the victims who are children facing enormous socio-ecological challenges. Other interventions with stigmatized populations report that an individualistic-focus places the blame and responsibility for one’s stigmatized condition on individuals and thereby reinforces the stigmatized label (Täuber et al., 2018). Therefore, we sought to develop a socioecological model to support the reintegration of SICY, pursuant to their expressed desires and consistent with current Kenyan policy.
Interventions must operate within their available scope of influence; within the communities of Meru County, Kenya, our intervention aims to address modifiable constructs and factors at two levels of the ecological model: (1) the children identified as living on the street and (2) the families of these children (Goodman et al., 2020). Through iterative action-reflection cycles, we developed a “4R + P” model to support children living on streets of three sub-counties in Meru County, Kenya – Rescue, Rehabilitation, Reintegration, Resocialization, and Prevention (Table 1). Program goals are to: (1) help interested SICY find their way off city streets (Rescue); (2)help rehabilitate SICY by providing a nurturing environment to detoxify from substance use, anti-social street behaviors, and reconnect with family, community mentors, and schools (Rehabilitation); (3) connect former SICY with their families of origin whenever possible and support these families to provide continuous on-going nurturing (Reintegration); (4) help children and youth form new identities that support their future roles as community members and leaders through caring for crops, animals, gaining marketable skills and re-initiating school attendance (Resocialization); and (5) strengthen families and communities to prevent the migration of children to the street and ensure children have secure and nurturing environments within which to grow and develop (Prevention).
Our strategy to reintegrate former SICY, and prevent their migration to the street, requires community engagement. Since 2017, we have been iteratively designing and testing features of the model we now call “Flourishing Communities” (Goodman et al., 2022a). Beginning with the home village of a child identified as living on the street, this program has grown to over 39 villages with over 10,000 weekly participating families (as of December 2022). While the overall model, intended to be generalizable beyond its specific context, is called Flourishing Communities, the program that continues to give rise and clarity to the Flourishing Community model is called “Kuja Pamoja kwa Jamii” (KPJ; Swahili for “Come Together for the place where we belong”). An adaptation and expansion of group-based microlending and communal governance approaches, more has been published on the KPJ design, organization and practices (Goodman et al., 2021a) and proposed psychosocial mechanisms (Goodman et al., 2022a).
The terminology “flourishing” was selected deliberately to underscore that while the communities that participate in the program face various challenges from multiple sources, levels, and histories, it is their potential and opportunities for growth that define the program staff’s relationship with them (Goodman et al., 2022a). While resilience is a process in response to adversity, flourishing is a process in response to opportunity. As communities experience both adversity and opportunity, resilient and flourishing processes overlap in lived experience as well as theoretical underpinnings. Yet, the ways in which outsiders frame and engage with communities influences communal self-perceptions and should be carefully considered (Muhammad et al., 2015). We anticipate that self-understandings that prioritize opportunities rather than adversities are more likely to support empowerment and respect human dignity. Definitions of resilience have included both an orientation toward adversity and new found opportunities, but we believe calling the latter definition “flourishing” clarifies this tension and places this work within other broad literature on psychosocial and economic dynamics of human flourishing (Shaw, 2012; VanderWeele, 2017). The Flourishing Community model is represented to program participants through use of the tree (Figure 3), and seeks to enhance structural resilience.
Resilience has been defined many different ways – ranging from intra-individual traits, states, or processes to adaptability of communities or organizations (Pooley and Cohen, 2010). This study approaches resilience as a structural process within a socio-ecology; there are certain socio-ecological positions that must be addressed and resolved before questions of individual-level resilience are posed ethically. At the center of this study is an investigation of “structural resilience” – what enables the possibility of changed structural relations for children and youth living in city streets of Meru County, Kenya. The construct of structural resilience describes the interacting and mutually supporting legal, economic, social, and political structures within a society that ensure equitable access to quality housing, education, and healthcare to promote people’s individual and collected self-determination (adapted from Panter-Brick, 2014). Structural resilience has appeared in scholarly literature occasionally over the past decade, but remains conceptually and operationally under-utilized (Southwick et al., 2014; Manjula and Srivastava, 2022). Within the policy shift toward reintegrating SICY, and children in institutional settings, the concept of structural resilience provides a framework to consider the socio-ecological factors that contribute to sustained reintegration and resocialization of SICY and primary prevention of their street-migration.
As displayed in Figure 3, the Flourishing Community model begins with inclusion and reconciliation (Phase 1). Inclusion may refer to inclusion of former SICY, their families, others who do not experience inclusion or require reconciliation with other program members. As roots draw resources into the tree, included and reconciled members of Flourishing Communities bring assets to the community and permit connection. The next phase (Phase 2) involves the establishment of lending groups who convene weekly to exchange $0.20–$0.50 with other members, and thereby generate social capital – expectations of reciprocity, trust, and shared capacity to improve their lives together (c.f. Goodman et al., 2021a,b, 2022b,c). As the trunk supports the structure of the tree, increased economic and social resources support the growth and structure of Flourishing Communities.
The social capital accrued through weekly microfinance participation enables members to address sources of on-going trauma, reduce depression, and build psychological assets like meaning in life, spirituality, curiosity, compassion, and self-compassion (Phase 3) (cf. Goodman et al., 2021b). To support this psychological development, we have created and are testing a novel positive psychology-based curriculum (“Pathways to Flourishing”), integrating insights from interpersonal theories of depression, psychological flexibility, and positive psychology (Kashdan and Rottenberg, 2010; Fredrickson, 2013; Hames et al., 2013; Seligman, 2018). As the xylem in trees carry water and dissolved minerals up from the roots of a tree to the leaves and fruit, positive psychological resources permit individuals and communities to “broaden and build” engagements and cultivate new opportunities and resources (Fredrickson, 2013).
Enhanced economic, social, and psychological resources permit communities to advocate for, and collaborate on, community resources and development across sectors and domains (Phase 4). In practice, this takes the appearance of advocating for and securing new water wells, school buildings, housing support, farming skills, HIV testing, peer support to reduce intimate partner violence, and other areas. The model presents an opportunity to consider how the Sustainable Development Goals may be integrated at the community level (cf. Stafford-Smith et al., 2017). As branches lead from the trunk of a tree in different directions and produce leaves to metabolize energy from the sun and flowers to recruit bees and promote pollination, organized, organic and empowered growth within Flourishing Communities can lead to improvements across multiple domains and support liaising with external resources.
Sustainable community growth and development leaves lasting benefits to future generations and inspires further community-led change within one’s own and in other communities (Phase 5). As fruit indicates the growth of healthy trees and carries seeds to develop other trees and their own fruit, the results of Flourishing Communities improvements across sectors and domains will result in lasting benefits and will inspire other communities. For more extensive discussion of the social psychology and facets of community development of the Flourishing Community model, (please see Goodman et al., 2022a).
Examples of measures reflecting the phases of the Flourishing Community model are presented in Table 2. These data are from on-going program evaluation to understand and inform processes by which the KPJ intervention may impact participants. While we have not yet assessed the interventional model through a randomized control trial, longitudinal data demonstrate evidence of effectiveness for the Flourishing Community model. Global sense of belonging, household monthly income, collective efficacy, compassion, depression, spirituality, HIV-related stigma and harsh child punishment all improve from the baseline (T1) occurring 1-year prior to the follow-up (T2) among active participants. The KPJ program has sufficient enrollment to permit multiple concurrent studies and exploration of measures (see Table 2 data).
The duration of time a child or youth spends on the streets influences the degree to which that person is socialized into the norms, attitudes and behaviors of street-life. For example, children who spend more time sleeping on the streets are at greater risk of substance use (Goodman et al., 2023). Overall, global prevalence estimates indicate 60% of SICY utilize some form of substance while on the street (Embleton et al., 2013). The degree to which duration on the streets or substance use patterns on the street impact reintegration prospects within sub-Saharan Africa has not been previously reported.
Children and youth face enormous adversity on city streets – encountering economic, emotional, physical and sexual abuse in addition to the social and material deprivations (Mathur et al., 2009). A previous study from Burundi found the number of traumatic life events and violent experiences during the previous 3-months predicted the number of classes attended by SICY at an institutional care facility (Crombach et al., 2014). The degree to which abuse experienced on the streets, which often compounds maltreatment experienced previous to living on the streets, influences prospects of SICY reintegration beyond institutional care facilities has also not been previously reported.
Crombach et al. (2014) found post-traumatic stress disorder mediated associations between previous traumatic experiences and class attendance at an institutional care facility in Burundi. Cultivating interests in activities and hobbies is recognized as a resilience-promoting practice, though it is unclear the extent to which this process may be mediated by the promotion of grit, self-esteem, self-efficacy, positive social identity, autonomy, self-regulation, or some other psychological trait (Gilligan, 1999; Howell, 2011). The degree to which SICY interests in activities on the street predict future reintegration prospects have not been reported within sub-Saharan Africa.
Finally, the KPJ/Flourishing Community model was developed to support families and communities from which SICY had left to live on streets. While the program shares features with other programs, we are unaware of any program integrating economic, social, health, and educational elements as does the KPJ program with the intention to support the reintegration of SICY (Goodman et al., 2020). Whether family participation in the KPJ, or similar, program is associated with reintegration prospects has not been reported within sub-Saharan Africa or other low- or middle-income contexts.
While the primary focus of this study is on immediate reintegration outcomes and significant predictors from the ARC program, we also evaluate whether participation in the KPJ program is associated with improved reintegration outcomes as intended. Figure 4 depicts theoretical relationships between two programs, an umbrella interventional model and the socio-ecological framework of structural resilience. An implied sub-aim of this study moves beyond immediate reintegration outcomes of SICY to assess validity of the hypothesized synergy between SICY-focused activities (the ARC program) and the community-based program to support families and communities of origin for SICY (the KPJ program). As depicted in Figure 4, these two programs, and the Flourishing Community model they inform, seek to improve structural resilience within a socio-ecological framework. This study is intended to lend support or nuance to this strategy.
The four data sources – intake form, exit form, follow-up form, and initial household interview – provided data that may be significantly associated with the defined outcome variable. These four sources provided information about different time points across the intervention’s relation to the child, and the child’s own history. These data were sorted into four different subsets for analysis according to theorized proximity to the outcome. Each subset was analyzed separately to identify variables that were significantly associated with the outcome before assessing retained variables in sequence from more distal to more proximal relation to the outcome. Statistically, it would not be possible to distinguish confounding, suppressing or mediating relations between variables, and there is insufficient theory and evidence to suggest probable pathways (MacKinnon et al., 2000).
All data were analyzed in STATA v.16.1 (StataCorp, 2019).
Figures 5A–C show (A) dates of enrollment, (B) months spent at ARC, and (C) duration of follow-up for all included children. Figure 5A demonstrates the increase in number of SICY supported through the program as the program transitioned from longer stay to shorter stay around January 2020. Figure 5B demonstrates the number of months children and youth have stayed at the ARC, with the largest number of SICY staying for less than 5 months. Figure 5C demonstrates the length of follow-up for each child.
Table 3 displays variables included in the outcomes or associated with the outcomes in analysis of a limited or full regression models. Over 50% of children who previously lived on the streets were reintegrated with their families and returned to school, with an additional 8% placed in boarding schools, 14% placed in polytechnical schools, and under 3% starting a business. Nearly 13% of participants left the program early, and nearly 10% were known to have relapsed to the streets at least once after being reintegrated to the broader community. As shown in Figure 6, there were a total of 253 initial records, of which 25 were repeated engagements with the same children. Of the 227 SICY who were rescued from the streets at one point, 29 left the program early and returned to life on the streets. Of the 197 SICY who were rehabilitated and reintegrated to some other location, 17 subsequently relapsed to the streets, leaving 180 (of the original 227) who were reintegrated with follow-up.
As shown in Table 3, the average child was 13 years old, and younger children were significantly more likely to be reintegrated with their families than another outcome. The average years of completed schooling was 4.9; age was not significantly different across outcome categories. Over 30% of children had families who owned land, which was 50% lower among children who relapsed or left the program early compared to children who were reintegrated to families of origin or another location. Over 1 in 5 children had family who could not be identified when they entered the program – arriving under government consent. Children who were reintegrated with a polytechnical or boarding school had the lowest percentage of children without identifiable family at intake. The mean years on the street (1.6 years; SD: 2) was significantly lower among children who were reintegrated with their families of origin than children who were in the other two outcome categories.
Table 4 shows the multinomial analyses of 4 data subsets.
Table 5 shows the combined, final multinomial logistic model comparing Outcome A (reintegrating to families of origin and attending school) to Outcome B (reintegrating some place other than with families of origin) or Outcome C (returning to the streets).
As data showed, the program underwent an evolution in its practice around the time of COVID-19, and in part as a response to government shutdowns to control the pandemic. As such, the number of children who passed through the program increased substantially between January 2020 and the most recent entrant in October 2022 (Figure 5a, above). The original consideration for keeping children at the ARC program for 2 years was informed partially by considerations of how to identify families of origin, recruit them to the KPJ program, and establish solid relationships and preparations for reintegration of children. Despite this intention, the majority of children returned to families of origin and did so from later waves of recruited SICY. Given the intention, and likely necessity, to support families and communities of origin to provide better support to children returning home from street situations, identifying mechanisms to rapidly respond to the reintegration of SICY by developing social support systems for the children and their families is essential. As data show, participation in the KPJ program is significantly associated with children not returning to street situations. The KPJ program demonstrates rapid growth and acceptability, positioning the strategy to combine reintegration efforts with community transformation efforts as meriting further research and development. The fact that duration on the street predicts significantly lower rates of reintegrating with families of origin indicates the need for early intervention with children who newly arrive on the streets. We previously found duration of time on the street predicts substance use (Goodman et al., 2023), which is consistent with socialization in street culture that protects SICY by providing an alternative social habitus to the broader culture (Hills et al., 2016). Extended time on the street may reinforce participation and identification with a sub-culture in opposition to the broader culture and may challenge any existing bonds of affection between SICY and their families. Rapid intervention appears necessary to promote family-based reintegration, requiring further shifts in community-based programming.
Children’s interests/desires at time of intake predicted subsequent outcomes. Children who expressed a desire to reintegrate with their families were more likely to do so. Children who expressed fewer interests in any activity (e.g., sports or socializing) prior to being admitted to the ARC were more likely to return to the streets subsequently. Lack of interest in activities is characteristic of depressive symptoms, but could be due to other socio-ecological or psychological factors. Mental health states conducive to successful reintegration should inform future research efforts, including depression, hope, and psychological resilience (e.g., Watson et al., 2020; Lenz, 2021).
Children who reported more abuse on the streets were less likely to reintegrate with their families of origin, controlling for an expressed desire to do so. This may be related to persistent PTSD, lack of sense of felt safety, or other psychosocial factors (Morton et al., 2022; Neuner, 2022; Wesarg et al., 2022).
Lingering traumatic experiences may complicate integration of children with families and communities of origin and may drive children to attribute their street-based hardships to their families of origin (Shaver, 2012). The extent to which these dynamics undermine family-based reintegration of SICY is unexplored to our knowledge. Depression, marked by a lack of interest, may also prevent children from wanting to envision alternatives to their street situations. Measurements of PTSD, attribution of guilt, felt safety, and depression may inform structural resilience initiatives with SICY (Derivois et al., 2017). Further, understanding how SICY form and express values, goals, and interests, and how to promote prosocial values and goals, may be a generative direction for structural resilience interventions.
We advocate for the adoption of structural resilience as a determinant of other forms of resilience for SICY. Exclusively individualistic notions of resilience are inadequate and potentially harmful. “What makes it possible for this child to endure separation from adults, and constant exposure to emotional, physical, sexual, and economic exploitation and deprivation better than other children?” is akin to asking what enables Black Americans in Tuskegee, Alabama to better endure untreated syphilis when a treatment is available (Freimuth et al., 2001).
Supporting structural re-location, such as living with nurturing families, is an essential part of caring for children living on the streets. Program data show that it is possible to reintegrate SICY with their families of origin – here more than 50% of the time. While this study focused on structural outcomes, there is a need to assess other measures of well-being, including academic, mental, and social aspects. Global consensus and empirically supported best practices are urgently needed to enhance the resilience of SICY. Structural resilience provides an over-arching framework to consider other constructs of resilience that may benefit SICY (Southwick et al., 2014). There is urgent need for global consensus on measures and empirically supported best-practices to increase structural, educational, social, mental, behavioral, and physical resilience of SICY.
In the future, we will assess the predictive validity of transdiagnostic, integrative measures that synthesize multiple socio-ecological levels, sectors and processes – such as the Child and Youth Resilience Measure, and the Process-Based Assessment Tool (CYRM-28; Van Rensburg et al., 2019; PBAT; Sanford et al., 2022). The urgency of the need for such consensus within the complexity of the situation animates our preference for transdiagnostic, multilevel, and process-based measurements.

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"[{\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B62\", \"B38\", \"B41\", \"B36\", \"B47\", \"B7\", \"B2\"], \"section\": \"1.1. Overview of challenges facing street-involved children and youth\", \"text\": \"The United Nations Children\\u2019s Fund has previously published estimates that tens of millions of children live on city streets globally, separated from adult caregivers (UNICEF, 2005). A notoriously difficult population to enumerate, street-involved children and youth (SICY) are vulnerable to multiple forms of abuse on the streets, human trafficking, substance misuse, and failure to thrive (Mathur et al., 2009; Nada and El Daw, 2010; Malindi and MacHenjedze, 2012; Pullum et al., 2012; Embleton et al., 2013; Aransiola and Zarowsky, 2014).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B55\", \"B59\", \"B59\", \"B26\"], \"section\": \"1.1. Overview of challenges facing street-involved children and youth\", \"text\": \"Published estimates of the number of Kenyan SICY range from 46,639 to 300,000 (Sorber et al., 2014; Street Families Rehabilitation Trust Fund, 2018). The study producing the lower estimate, released by the Kenyan Ministry of Labour and Social Protection in 2018, faced multiple limitations undermining its reliability \\u2013 such as distrust between enumerators and children, budget over-runs due to the need for increased security, language barriers between interviewers and children, and criminal cartels who interfered with the underfunded study (Street Families Rehabilitation Trust Fund, 2018). The higher estimate is regularly cited as authoritative in peer-reviewed literature; however, it was released as a report from a news agency in 2007, citing the estimates of experts without peer-reviewed analysis or methodological transparency (IRIN, 2007).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"F1\", \"B45\", \"B64\", \"B29\", \"B27\", \"B28\"], \"section\": \"1.2. The Socio-ecological context of street-involved children and youth in sub-Saharan Africa\", \"text\": \"The phenomenon of children living on the street is a multi-level problem, understood best through Bronfenbrenner\\u2019s socio-ecological model. Figure 1 displays a non-exhaustive compilation of known factors associated with street-migration among children. Across time (chronosystem), industrialization and dominant global economic development models contribute to urbanization (Patil, 2014). According to United Nations data, the percentage of population living in urban areas in Eastern Africa increased fourfold between 1950 and 2020 \\u2013 equal to the growth in Kenya (United Nations, Department of Economic and Social Affairs, Population Division [UNDESAPD], 2018). Across sub-Saharan Africa, including in Kenya, urbanization followed railways placed by colonizing European country governments \\u2013 a trajectory that continued after railways became less utilized (Jedwab and Moradi, 2016; Jedwab et al., 2017a). At the beginning of the 20th century, sub-Saharan Africa contained only about 50 cities with 10,000 or more inhabitants. By 2010, the number of cities with at least 10,000 inhabitants grew to almost 3,000 (Jedwab et al., 2017b).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B8\", \"B1\", \"B4\", \"B61\", \"B9\"], \"section\": \"1.2. The Socio-ecological context of street-involved children and youth in sub-Saharan Africa\", \"text\": \"The emergence of cities, new economic opportunities and political economies influence macro-, exo-, meso-, and micro-systems impacting risk of street migration among children. One example of the impact urbanization and new migration routes have on communities and families is the early geographic spread of HIV \\u2013 which followed economic routes created by colonizing forces (Faria et al., 2014). While it is difficult to trace the numerical rise of SICY across colonizer-induced dynamics, urbanization is a necessary element for children to sleep on city streets. Further exacerbating disruptive inequities due to forced participation in the globalized economy, the structural adjustment programs inspired by the Washington Consensus and championed by the great powers in the late 1980s exacerbated the relative standing of rural communities, women and children with respect to health outcomes, income, education, and social cohesion (Ahmed and Lipton, 1997; Craig and Porter, 2005; Thomson et al., 2017; Forster et al., 2020).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B65\", \"B43\", \"B63\"], \"section\": \"1.3. Policy environment related to interventions with street-involved children and youth\", \"text\": \"There is a dire need for evidence-informed programmatic and policy interventions to support the wellbeing and self-determination of SICY. In 2010, the United Nations General Assembly adopted a resolution calling for member states to shift from placement of children in long-term care facilities toward reintegration of separated children (United Nations General Assembly [UNGA], 2010). In 2012, the United Nations High Commissioner for Human Rights published a report on \\u201cthe protection and promotion of the rights of children working and/or living on the street.\\u201d The report recognized governments as primary duty-bearers to meet the obligation of having the rights of children respected and fulfilled. The UN High Commission report required States to present legislation to mandate municipal policies and resource-coordinated interventions for SICY (Office of the High Commissioner for Human Rights [OHCHR], 2012). The United Nations Convention on the Rights of the Child issued a general comment in 2017 aiming to provide comprehensive, authoritative guidance to States toward a holistic, rights-based approach to prevent street-migration of children and ensure a continuum of care for SICY to develop their fullest potential (UN Committee on the Rights of the Child, 2017).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B31\", \"B33\", \"B34\", \"B3\"], \"section\": \"1.3. Policy environment related to interventions with street-involved children and youth\", \"text\": \"Kenya is one of many low- and middle-income countries working to address the social and health challenges confronting SICY. In 2022, the national government of Kenya released its National Care Reform Strategy for Children endorsing reforms to (1) prevent family separation and promote family strengthening, (2) support alternative care and transition away from institutional care, and (3) trace, reintegrate and transition to family- and community-based care (Kenya Ministry of Labour and Social Protection, 2022). Kenya\\u2019s national plan for care reform includes efforts to defund institutionalization of children, a plan that is supported by good evidence (e.g., Lionetti et al., 2015; Lyneham and Facchini, 2019). However, due to the paucity of evidence, neither the UN resolution nor the Kenya Care Reform strategy provides evidence to support the perspective that SICY can be successfully reintegrated with families of origin or foster families. A 2016 global review of literature presenting interventional effectiveness of programs designed to reintegrate SICY found no studies measuring inclusion and reintegration of SICY anywhere in the world, and no studies exploring interventional outcomes of programs in low- or middle-income countries (Coren et al., 2016). Evidence-informed strategies are required to ensure that children living on the streets are not simply placed back in abusive or unstable families they fled when they initially migrated to the streets.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B50\", \"B51\", \"F2\", \"B21\", \"B20\", \"B69\"], \"section\": \"1.4. Study interventional context\", \"text\": \"A team of public health researchers, community leaders and social workers, our own work with SICY began in 2012 in response to local concerns about the growing number of children who were migrating to the streets of Meru County, Kenya (Seidel et al., 2017, 2018). Figure 2 illustrates the heterogeneity of households reporting street-migration of children between communities within three sub-counties in Meru County, stratified by HIV-status. Statistically significant variation in probability of reporting a child lives on the street differs by HIV-status of adults in the household and village location (Goodman et al., 2016). Mixed methods research reveals multiple community- and family-level predictors of street-migration \\u2013 including maternal childhood adversities, maternal years of schooling, family cohesion, financial resources, parental mental health, substance use, and maternal social support (Goodman et al., 2017). Learning disabilities appear at higher rates among street-involved children than within the broader population, indicating child-level differences that may contribute to street-migration risk (Ward and Seager, 2010).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B20\"], \"section\": \"\", \"text\": \"Variation in street-migration by village and parental HIV status within three Kenyan sub-counties. Data from Goodman et al. (2017).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B48\", \"B12\", \"B66\", \"B60\"], \"section\": \"1.4.1. Risk of stigma from non-contextualized interventions\", \"text\": \"Despite the complex socioecology of street-migration among children, many SICY experience high rates of stigma related to life on the streets (Rivenbark et al., 2018; Gayapersad et al., 2020). Often interventions to assist vulnerable children and promote child resilience are not adequately informed by a socio-ecological model and may risk reinforcing an individualistic view of children\\u2019s resilience capacities (van Breda and Theron, 2018). An individualistic focus is particularly unhelpful, and blames the victims who are children facing enormous socio-ecological challenges. Other interventions with stigmatized populations report that an individualistic-focus places the blame and responsibility for one\\u2019s stigmatized condition on individuals and thereby reinforces the stigmatized label (T\\u00e4uber et al., 2018). Therefore, we sought to develop a socioecological model to support the reintegration of SICY, pursuant to their expressed desires and consistent with current Kenyan policy.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B19\", \"T1\"], \"section\": \"1.5. Study interventional design\", \"text\": \"Interventions must operate within their available scope of influence; within the communities of Meru County, Kenya, our intervention aims to address modifiable constructs and factors at two levels of the ecological model: (1) the children identified as living on the street and (2) the families of these children (Goodman et al., 2020). Through iterative action-reflection cycles, we developed a \\u201c4R + P\\u201d model to support children living on streets of three sub-counties in Meru County, Kenya \\u2013 Rescue, Rehabilitation, Reintegration, Resocialization, and Prevention (Table 1). Program goals are to: (1) help interested SICY find their way off city streets (Rescue); (2)help rehabilitate SICY by providing a nurturing environment to detoxify from substance use, anti-social street behaviors, and reconnect with family, community mentors, and schools (Rehabilitation); (3) connect former SICY with their families of origin whenever possible and support these families to provide continuous on-going nurturing (Reintegration); (4) help children and youth form new identities that support their future roles as community members and leaders through caring for crops, animals, gaining marketable skills and re-initiating school attendance (Resocialization); and (5) strengthen families and communities to prevent the migration of children to the street and ensure children have secure and nurturing environments within which to grow and develop (Prevention).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B14\", \"B17\", \"B14\"], \"section\": \"1.5.2. Introducing the Flourishing Community model and the KPJ program\", \"text\": \"Our strategy to reintegrate former SICY, and prevent their migration to the street, requires community engagement. Since 2017, we have been iteratively designing and testing features of the model we now call \\u201cFlourishing Communities\\u201d (Goodman et al., 2022a). Beginning with the home village of a child identified as living on the street, this program has grown to over 39 villages with over 10,000 weekly participating families (as of December 2022). While the overall model, intended to be generalizable beyond its specific context, is called Flourishing Communities, the program that continues to give rise and clarity to the Flourishing Community model is called \\u201cKuja Pamoja kwa Jamii\\u201d (KPJ; Swahili for \\u201cCome Together for the place where we belong\\u201d). An adaptation and expansion of group-based microlending and communal governance approaches, more has been published on the KPJ design, organization and practices (Goodman et al., 2021a) and proposed psychosocial mechanisms (Goodman et al., 2022a).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B14\", \"B40\", \"B54\", \"B68\", \"F3\"], \"section\": \"1.5.2.1. Distinctions and similarities between flourishing and resilience\", \"text\": \"The terminology \\u201cflourishing\\u201d was selected deliberately to underscore that while the communities that participate in the program face various challenges from multiple sources, levels, and histories, it is their potential and opportunities for growth that define the program staff\\u2019s relationship with them (Goodman et al., 2022a). While resilience is a process in response to adversity, flourishing is a process in response to opportunity. As communities experience both adversity and opportunity, resilient and flourishing processes overlap in lived experience as well as theoretical underpinnings. Yet, the ways in which outsiders frame and engage with communities influences communal self-perceptions and should be carefully considered (Muhammad et al., 2015). We anticipate that self-understandings that prioritize opportunities rather than adversities are more likely to support empowerment and respect human dignity. Definitions of resilience have included both an orientation toward adversity and new found opportunities, but we believe calling the latter definition \\u201cflourishing\\u201d clarifies this tension and places this work within other broad literature on psychosocial and economic dynamics of human flourishing (Shaw, 2012; VanderWeele, 2017). The Flourishing Community model is represented to program participants through use of the tree (Figure 3), and seeks to enhance structural resilience.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B46\", \"B44\", \"B56\", \"B37\"], \"section\": \"1.5.2.2. Structural resilience\", \"text\": \"Resilience has been defined many different ways \\u2013 ranging from intra-individual traits, states, or processes to adaptability of communities or organizations (Pooley and Cohen, 2010). This study approaches resilience as a structural process within a socio-ecology; there are certain socio-ecological positions that must be addressed and resolved before questions of individual-level resilience are posed ethically. At the center of this study is an investigation of \\u201cstructural resilience\\u201d \\u2013 what enables the possibility of changed structural relations for children and youth living in city streets of Meru County, Kenya. The construct of structural resilience describes the interacting and mutually supporting legal, economic, social, and political structures within a society that ensure equitable access to quality housing, education, and healthcare to promote people\\u2019s individual and collected self-determination (adapted from Panter-Brick, 2014). Structural resilience has appeared in scholarly literature occasionally over the past decade, but remains conceptually and operationally under-utilized (Southwick et al., 2014; Manjula and Srivastava, 2022). Within the policy shift toward reintegrating SICY, and children in institutional settings, the concept of structural resilience provides a framework to consider the socio-ecological factors that contribute to sustained reintegration and resocialization of SICY and primary prevention of their street-migration.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"F3\", \"B17\", \"B18\", \"B15\", \"B16\"], \"section\": \"1.5.3. The 5-phase scaffolding approach to Flourishing Community\", \"text\": \"As displayed in Figure 3, the Flourishing Community model begins with inclusion and reconciliation (Phase 1). Inclusion may refer to inclusion of former SICY, their families, others who do not experience inclusion or require reconciliation with other program members. As roots draw resources into the tree, included and reconciled members of Flourishing Communities bring assets to the community and permit connection. The next phase (Phase 2) involves the establishment of lending groups who convene weekly to exchange $0.20\\u2013$0.50 with other members, and thereby generate social capital \\u2013 expectations of reciprocity, trust, and shared capacity to improve their lives together (c.f. Goodman et al., 2021a,b, 2022b,c). As the trunk supports the structure of the tree, increased economic and social resources support the growth and structure of Flourishing Communities.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B18\", \"B30\", \"B10\", \"B23\", \"B52\", \"B10\"], \"section\": \"1.5.3. The 5-phase scaffolding approach to Flourishing Community\", \"text\": \"The social capital accrued through weekly microfinance participation enables members to address sources of on-going trauma, reduce depression, and build psychological assets like meaning in life, spirituality, curiosity, compassion, and self-compassion (Phase 3) (cf. Goodman et al., 2021b). To support this psychological development, we have created and are testing a novel positive psychology-based curriculum (\\u201cPathways to Flourishing\\u201d), integrating insights from interpersonal theories of depression, psychological flexibility, and positive psychology (Kashdan and Rottenberg, 2010; Fredrickson, 2013; Hames et al., 2013; Seligman, 2018). As the xylem in trees carry water and dissolved minerals up from the roots of a tree to the leaves and fruit, positive psychological resources permit individuals and communities to \\u201cbroaden and build\\u201d engagements and cultivate new opportunities and resources (Fredrickson, 2013).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B57\"], \"section\": \"1.5.3. The 5-phase scaffolding approach to Flourishing Community\", \"text\": \"Enhanced economic, social, and psychological resources permit communities to advocate for, and collaborate on, community resources and development across sectors and domains (Phase 4). In practice, this takes the appearance of advocating for and securing new water wells, school buildings, housing support, farming skills, HIV testing, peer support to reduce intimate partner violence, and other areas. The model presents an opportunity to consider how the Sustainable Development Goals may be integrated at the community level (cf. Stafford-Smith et al., 2017). As branches lead from the trunk of a tree in different directions and produce leaves to metabolize energy from the sun and flowers to recruit bees and promote pollination, organized, organic and empowered growth within Flourishing Communities can lead to improvements across multiple domains and support liaising with external resources.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B14\"], \"section\": \"1.5.3. The 5-phase scaffolding approach to Flourishing Community\", \"text\": \"Sustainable community growth and development leaves lasting benefits to future generations and inspires further community-led change within one\\u2019s own and in other communities (Phase 5). As fruit indicates the growth of healthy trees and carries seeds to develop other trees and their own fruit, the results of Flourishing Communities improvements across sectors and domains will result in lasting benefits and will inspire other communities. For more extensive discussion of the social psychology and facets of community development of the Flourishing Community model, (please see Goodman et al., 2022a).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"T2\", \"T2\"], \"section\": \"1.5.3. The 5-phase scaffolding approach to Flourishing Community\", \"text\": \"Examples of measures reflecting the phases of the Flourishing Community model are presented in Table 2. These data are from on-going program evaluation to understand and inform processes by which the KPJ intervention may impact participants. While we have not yet assessed the interventional model through a randomized control trial, longitudinal data demonstrate evidence of effectiveness for the Flourishing Community model. Global sense of belonging, household monthly income, collective efficacy, compassion, depression, spirituality, HIV-related stigma and harsh child punishment all improve from the baseline (T1) occurring 1-year prior to the follow-up (T2) among active participants. The KPJ program has sufficient enrollment to permit multiple concurrent studies and exploration of measures (see Table 2 data).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B22\", \"B7\"], \"section\": \"1.6.1. Study data context\", \"text\": \"The duration of time a child or youth spends on the streets influences the degree to which that person is socialized into the norms, attitudes and behaviors of street-life. For example, children who spend more time sleeping on the streets are at greater risk of substance use (Goodman et al., 2023). Overall, global prevalence estimates indicate 60% of SICY utilize some form of substance while on the street (Embleton et al., 2013). The degree to which duration on the streets or substance use patterns on the street impact reintegration prospects within sub-Saharan Africa has not been previously reported.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B38\", \"B5\"], \"section\": \"1.6.1. Study data context\", \"text\": \"Children and youth face enormous adversity on city streets \\u2013 encountering economic, emotional, physical and sexual abuse in addition to the social and material deprivations (Mathur et al., 2009). A previous study from Burundi found the number of traumatic life events and violent experiences during the previous 3-months predicted the number of classes attended by SICY at an institutional care facility (Crombach et al., 2014). The degree to which abuse experienced on the streets, which often compounds maltreatment experienced previous to living on the streets, influences prospects of SICY reintegration beyond institutional care facilities has also not been previously reported.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B5\", \"B13\", \"B25\"], \"section\": \"1.6.1. Study data context\", \"text\": \"Crombach et al. (2014) found post-traumatic stress disorder mediated associations between previous traumatic experiences and class attendance at an institutional care facility in Burundi. Cultivating interests in activities and hobbies is recognized as a resilience-promoting practice, though it is unclear the extent to which this process may be mediated by the promotion of grit, self-esteem, self-efficacy, positive social identity, autonomy, self-regulation, or some other psychological trait (Gilligan, 1999; Howell, 2011). The degree to which SICY interests in activities on the street predict future reintegration prospects have not been reported within sub-Saharan Africa.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B19\"], \"section\": \"1.6.1. Study data context\", \"text\": \"Finally, the KPJ/Flourishing Community model was developed to support families and communities from which SICY had left to live on streets. While the program shares features with other programs, we are unaware of any program integrating economic, social, health, and educational elements as does the KPJ program with the intention to support the reintegration of SICY (Goodman et al., 2020). Whether family participation in the KPJ, or similar, program is associated with reintegration prospects has not been reported within sub-Saharan Africa or other low- or middle-income contexts.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"F4\", \"F4\"], \"section\": \"1.7.1. Implied sub-aim\", \"text\": \"While the primary focus of this study is on immediate reintegration outcomes and significant predictors from the ARC program, we also evaluate whether participation in the KPJ program is associated with improved reintegration outcomes as intended. Figure 4 depicts theoretical relationships between two programs, an umbrella interventional model and the socio-ecological framework of structural resilience. An implied sub-aim of this study moves beyond immediate reintegration outcomes of SICY to assess validity of the hypothesized synergy between SICY-focused activities (the ARC program) and the community-based program to support families and communities of origin for SICY (the KPJ program). As depicted in Figure 4, these two programs, and the Flourishing Community model they inform, seek to improve structural resilience within a socio-ecological framework. This study is intended to lend support or nuance to this strategy.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B35\"], \"section\": \"2.3.2. Predictor variables\", \"text\": \"The four data sources \\u2013 intake form, exit form, follow-up form, and initial household interview \\u2013 provided data that may be significantly associated with the defined outcome variable. These four sources provided information about different time points across the intervention\\u2019s relation to the child, and the child\\u2019s own history. These data were sorted into four different subsets for analysis according to theorized proximity to the outcome. Each subset was analyzed separately to identify variables that were significantly associated with the outcome before assessing retained variables in sequence from more distal to more proximal relation to the outcome. Statistically, it would not be possible to distinguish confounding, suppressing or mediating relations between variables, and there is insufficient theory and evidence to suggest probable pathways (MacKinnon et al., 2000).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B58\"], \"section\": \"2.3.5. Data analysis software\", \"text\": \"All data were analyzed in STATA v.16.1 (StataCorp, 2019).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"F5\", \"F5\", \"F5\", \"F5\"], \"section\": \"3.1. Visualizing program exposures\", \"text\": \"Figures 5A\\u2013C show (A) dates of enrollment, (B) months spent at ARC, and (C) duration of follow-up for all included children. Figure 5A demonstrates the increase in number of SICY supported through the program as the program transitioned from longer stay to shorter stay around January 2020. Figure 5B demonstrates the number of months children and youth have stayed at the ARC, with the largest number of SICY staying for less than 5 months. Figure 5C demonstrates the length of follow-up for each child.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"T3\", \"F6\"], \"section\": \"3.2. Descriptive outcomes of sample\", \"text\": \"Table 3 displays variables included in the outcomes or associated with the outcomes in analysis of a limited or full regression models. Over 50% of children who previously lived on the streets were reintegrated with their families and returned to school, with an additional 8% placed in boarding schools, 14% placed in polytechnical schools, and under 3% starting a business. Nearly 13% of participants left the program early, and nearly 10% were known to have relapsed to the streets at least once after being reintegrated to the broader community. As shown in Figure 6, there were a total of 253 initial records, of which 25 were repeated engagements with the same children. Of the 227 SICY who were rescued from the streets at one point, 29 left the program early and returned to life on the streets. Of the 197 SICY who were rehabilitated and reintegrated to some other location, 17 subsequently relapsed to the streets, leaving 180 (of the original 227) who were reintegrated with follow-up.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"T3\"], \"section\": \"3.2.1. Comparison of variables across outcome strata\", \"text\": \"As shown in Table 3, the average child was 13 years old, and younger children were significantly more likely to be reintegrated with their families than another outcome. The average years of completed schooling was 4.9; age was not significantly different across outcome categories. Over 30% of children had families who owned land, which was 50% lower among children who relapsed or left the program early compared to children who were reintegrated to families of origin or another location. Over 1 in 5 children had family who could not be identified when they entered the program \\u2013 arriving under government consent. Children who were reintegrated with a polytechnical or boarding school had the lowest percentage of children without identifiable family at intake. The mean years on the street (1.6 years; SD: 2) was significantly lower among children who were reintegrated with their families of origin than children who were in the other two outcome categories.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"T4\"], \"section\": \"3.3. Comparing outcomes across subsets of data\", \"text\": \"Table 4 shows the multinomial analyses of 4 data subsets.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"T5\"], \"section\": \"3.4. Final model of outcomes\", \"text\": \"Table 5 shows the combined, final multinomial logistic model comparing Outcome A (reintegrating to families of origin and attending school) to Outcome B (reintegrating some place other than with families of origin) or Outcome C (returning to the streets).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"F5\", \"B22\", \"B24\"], \"section\": \"4.1. Program findings\", \"text\": \"As data showed, the program underwent an evolution in its practice around the time of COVID-19, and in part as a response to government shutdowns to control the pandemic. As such, the number of children who passed through the program increased substantially between January 2020 and the most recent entrant in October 2022 (Figure 5a, above). The original consideration for keeping children at the ARC program for 2 years was informed partially by considerations of how to identify families of origin, recruit them to the KPJ program, and establish solid relationships and preparations for reintegration of children. Despite this intention, the majority of children returned to families of origin and did so from later waves of recruited SICY. Given the intention, and likely necessity, to support families and communities of origin to provide better support to children returning home from street situations, identifying mechanisms to rapidly respond to the reintegration of SICY by developing social support systems for the children and their families is essential. As data show, participation in the KPJ program is significantly associated with children not returning to street situations. The KPJ program demonstrates rapid growth and acceptability, positioning the strategy to combine reintegration efforts with community transformation efforts as meriting further research and development. The fact that duration on the street predicts significantly lower rates of reintegrating with families of origin indicates the need for early intervention with children who newly arrive on the streets. We previously found duration of time on the street predicts substance use (Goodman et al., 2023), which is consistent with socialization in street culture that protects SICY by providing an alternative social habitus to the broader culture (Hills et al., 2016). Extended time on the street may reinforce participation and identification with a sub-culture in opposition to the broader culture and may challenge any existing bonds of affection between SICY and their families. Rapid intervention appears necessary to promote family-based reintegration, requiring further shifts in community-based programming.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B70\", \"B32\"], \"section\": \"4.1.1. Children\\u2019s self-determination and mental health\", \"text\": \"Children\\u2019s interests/desires at time of intake predicted subsequent outcomes. Children who expressed a desire to reintegrate with their families were more likely to do so. Children who expressed fewer interests in any activity (e.g., sports or socializing) prior to being admitted to the ARC were more likely to return to the streets subsequently. Lack of interest in activities is characteristic of depressive symptoms, but could be due to other socio-ecological or psychological factors. Mental health states conducive to successful reintegration should inform future research efforts, including depression, hope, and psychological resilience (e.g., Watson et al., 2020; Lenz, 2021).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B39\", \"B42\", \"B71\"], \"section\": \"4.1.2. Potential post-traumatic stress, blame attribution, and depression\", \"text\": \"Children who reported more abuse on the streets were less likely to reintegrate with their families of origin, controlling for an expressed desire to do so. This may be related to persistent PTSD, lack of sense of felt safety, or other psychosocial factors (Morton et al., 2022; Neuner, 2022; Wesarg et al., 2022).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B53\", \"B6\"], \"section\": \"4.1.2. Potential post-traumatic stress, blame attribution, and depression\", \"text\": \"Lingering traumatic experiences may complicate integration of children with families and communities of origin and may drive children to attribute their street-based hardships to their families of origin (Shaver, 2012). The extent to which these dynamics undermine family-based reintegration of SICY is unexplored to our knowledge. Depression, marked by a lack of interest, may also prevent children from wanting to envision alternatives to their street situations. Measurements of PTSD, attribution of guilt, felt safety, and depression may inform structural resilience initiatives with SICY (Derivois et al., 2017). Further, understanding how SICY form and express values, goals, and interests, and how to promote prosocial values and goals, may be a generative direction for structural resilience interventions.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B11\"], \"section\": \"4.2. Structural resilience-related discussion\", \"text\": \"We advocate for the adoption of structural resilience as a determinant of other forms of resilience for SICY. Exclusively individualistic notions of resilience are inadequate and potentially harmful. \\u201cWhat makes it possible for this child to endure separation from adults, and constant exposure to emotional, physical, sexual, and economic exploitation and deprivation better than other children?\\u201d is akin to asking what enables Black Americans in Tuskegee, Alabama to better endure untreated syphilis when a treatment is available (Freimuth et al., 2001).\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B56\"], \"section\": \"4.2. Structural resilience-related discussion\", \"text\": \"Supporting structural re-location, such as living with nurturing families, is an essential part of caring for children living on the streets. Program data show that it is possible to reintegrate SICY with their families of origin \\u2013 here more than 50% of the time. While this study focused on structural outcomes, there is a need to assess other measures of well-being, including academic, mental, and social aspects. Global consensus and empirically supported best practices are urgently needed to enhance the resilience of SICY. Structural resilience provides an over-arching framework to consider other constructs of resilience that may benefit SICY (Southwick et al., 2014). There is urgent need for global consensus on measures and empirically supported best-practices to increase structural, educational, social, mental, behavioral, and physical resilience of SICY.\"}, {\"pmc\": \"PMC10482225\", \"pmid\": \"37680240\", \"reference_ids\": [\"B67\", \"B49\"], \"section\": \"4.2. Structural resilience-related discussion\", \"text\": \"In the future, we will assess the predictive validity of transdiagnostic, integrative measures that synthesize multiple socio-ecological levels, sectors and processes \\u2013 such as the Child and Youth Resilience Measure, and the Process-Based Assessment Tool (CYRM-28; Van Rensburg et al., 2019; PBAT; Sanford et al., 2022). The urgency of the need for such consensus within the complexity of the situation animates our preference for transdiagnostic, multilevel, and process-based measurements.\"}]"

Metadata

"{\"section-at-acceptance\": \"Developmental Psychology\"}"