Disadvantages of being a street child in Iran: a systematic review

Abstract

In order to find related family factors and outcomes of being a street child in Iran, this study has classified and evaluated studies on this issue from a recent decade according to their strengths and weaknesses. We used a systematic review method in this study. By searching Iranian and international databases, and many universities and related organisations in Iran, and after their quality had been evaluated by a quality evaluation form, the findings of 40 studies were described and analysed. Street children in Iran are confronted with some serious family disadvantages such as family breakdown and abuse that may, along with poverty, push them to the streets. Many children also suffer from physical and mental health problems, and are involved in delinquency and drug abuse. It seems that both mechanisms of poverty and adverse familial conditions drive children to leave their homes for the streets as a way to solve their problems.

Keywords::

• Iran
• meta-analysis
• related factors
• street children
• systematic review

Introduction

The number of street children is growing globally, according to UNICEF (2005): ‘The exact number of street children is impossible to quantify, but it is likely to number in the tens of millions or higher, some estimates place the figure as high as 100 million’. In Iran, the problem of street children is considered one of the most important social problems in recent decades (Shaaverdi, 2004; Vameghi, 2006). As indexed in Namaye, an Iranian electronic database,1 there were at least 100 interviews, reports and essays about street children between 1996 and 2006 published in newspapers and magazines across the country. Although there is no official statistic or estimate of the number of street children in the country, their presence and working in the streets as an emergent phenomenon in contrast to the Iranian collective and family-based culture and value system led many researchers to identify the individual and social factors related to becoming street children and their outcomes.

Factors related to becoming a street child at a glance

Many studies considered street children as products of poverty (Aptekar, 1994; Ferguson, 2005; Khan & Hesketh, 2010; Ward & Seager, 2010) and/or dysfunctional families (Khan & Hesketh, 2010; Panter-Brick, 2002; Scanlon, Tomkins, Lynch, & Scanlon, 1998). Some other studies revealed that, although poverty has a role in becoming a street child, familial conflict is the major factor (Patel, 1990; Subrahmanyam & Sondhi, 1990).

Rapid assessment of street children in Cairo and Alexandria (World Food Program & United Nations Children's Fund, United Nations Office for Drug Control and Crime Prevention, 2001) classified factors of leading to this phenomenon into two groups: indirect factors that pave the children's way to the streets (i.e. low parental income and low education, familial disruption, family size, dropping out of school, unplanned migration, decrease of family role in problem-solving for children, especially in urban areas); and direct factors that street children themselves often mention (i.e. the role of their friends in persuading them to leave home and to live on the streets).

On the whole, despite the variation in the results of studies and the multi-factorial nature of the problem, poverty and familial factors such as child abuse and lack of effective supervision are the major causes of becoming street children.

A view of the outcomes of being a street child

Reviewing the literature on street children in different countries has confirmed the existence of physical, mental and social problems in these children (Scivoletto, Da Silva, & Rosenheck, 2011). Thuderic-Ghemo (2005), in a review of studies about street children in Russia, Colombia, Bulgaria, India, Rwanda, Kenya, South Africa, Swaziland and Zimbabwe, showed that living on the street causes some normally treatable diseases (e.g. malnutrition, severe weight loss, pneumonia, malaria, nausea) and some problems due to cold air such as sore throat, headache and nasal irritation, skin diseases such as lice and scabies, and sores around the mouth. Long-standing effects of diseases in street children caused damage in the central nervous system, heart, liver, kidney and bone marrow, and consequently these hazards caused a higher risk of mortality among them. Van-Rooyan & Hartell (2002) believe that, in addition to physical problems, street children have been ignored psychologically, resulting in their insufficient growth. Also, Adlaf and Zdanowicz in 1999 showed that 30–40% of street children had reported depression, paranoid ideas, conduct disorder and suicide (cited in Thuderic-Ghemo, 2005).

Street children are exposed to other hazards. Based on the United Nations study ‘Violence against Children’, they mainly had a history of runaway, and physical and sexual abuse in Canada, making them extremely vulnerable to sexual exploitation. To care for themselves, many street children are involved in begging, drug trafficking, stealing, prostitution or survival sex (offering sex for food, shelter and medicine) (Save The Children, 2005). Overall, the findings of several studies indicate that street children are exposed to severe risks of physical, mental and social problems.

Disadvantages of street children in Iran

In response to the continuing problem of street children in Iran, many institutes and universities have tended to study the issue. Because of the existence of so many noticeable researches in the country and the need for evidence-based policy-making, planning and intervention, evaluating and summarising the results is necessary. This study intended to collect and classify research evidence on the aetiology of becoming street children and the outcomes of being street children. Of the variables researched in studies, some could be considered either risk factors for becoming a street child or its outcomes based on their nature, but their designs, which were cross-sectional, correlational or case–control, prevent us from drawing such a conclusion. Therefore, based on their dual nature, we preferred to name all of them as ‘disadvantages’ instead of either risk factors or outcomes, keeping in mind the potentiality of being one of the two.

Method

A street child is defined by the United Nations as ‘any girl or boy for whom the street in the widest sense of the word (including unoccupied dwellings, wasteland, etc.) has become his or her habitual abode and/or source of livelihood, and who is inadequately protected, supervised, or directed by responsible adults’ (Aptekar, 1994). Keeping this definition in mind, we defined the term ‘street children’ as any children who live and/or work on the streets, whether or not such working is related to her/his family and adult supervisors or supporters.

Search strategy

A comprehensive and systematic search for all types of quantitative studies on street children in Iran and their families was conducted in Persian and English literature. We used two main strategies to identify relevant studies about street children in Iran and their families. First, we searched electronic Iranian databases including Irandoc (Iranian Research Institute for Information Science and Technology), Iranmedex, SID (Scientific Information Database), Magiran, IranPsych (Iranian Databases on Mental Health, Psychiatric and Psychological Research), National Library & Archives of Iran, Social Problems Database of the University of Social Welfare and Rehabilitation Science, Database of Street and Working Children of Tak e Sarzamin e Man Institute, and international databases (i.e. Index Medicus of Eastern Mediterranean Regional Office, ISI Web of Science, Medline and Embase) for published studies.2 Second, we searched the grey literature (i.e. organisational reports, dissertations and research reports) in central libraries in Tehran of all related universities and research centres, and governmental and non-governmental organisations, related to social problems for potentially relevant studies. Documents that appeared to be relevant on the basis of titles were captured. Abstracts of selected titles were then assessed according to our inclusion and exclusion criteria. Persian and English databases were searched by 16 keywords in Farsi and English (Vameghi et al, 2012).

Inclusion/exclusion criteria

Eligibility criteria were developed specifically for responding to the questions of the systematic review. Therefore, studies whose target populations were street children and/or their families who were living in Iran, undertaken between 1998 and 2007, and whose approach was quantitative, were included.

First, two of the researchers independently reviewed each study to decide on its inclusion in the review process. In the case of any disagreement or vagueness, all three researchers met together to discuss and make the final decision.

Quality assessment

The research team developed two checklists for evaluating the quality of the descriptive and analytical studies. After reviewing the relevant tools, such as the Critical Appraisal Skills Program (Public Health Resource Unit, 2006) and the Guidelines for Evaluating Prevalence Studies (Boyle, 1998), a new checklist, suitable for our purposes, was developed. The reliability of the checklist was assessed in a pilot phase before applying it to all the selected studies. The methodological checklist for the descriptive studies and the descriptive findings of the analytical studies assessed the following criteria: sample size, sampling method, reliability and validity of data collection. The checklist for the analytical studies covered the following areas: appropriateness of the aim of the research with the study design, control of confounding variables, suitability of the selection of samples in the study group(s), appropriateness of the measurements, and appropriateness of the statistical analyses (e.g. odds ratio, coefficient of correlation, p value and confidence interval) used in the study. Inclusion and appraisal criteria are shown in Table 1. The three reviewers assessed each document for study quality.

Table 1 Inclusion criteria and appraisal criteria of studies.

Inclusion criteria	Critical appraisal criteria
	Descriptive findings	Analytical findings
Quantitative studies	Suitable sample size for study variables	Appropriate study design regarding the aim of the study
Studies were undertaken between 1998 and 2007	Sampling method (random or convenient sampling for sampling in street and open-door centres and random sampling for closed-door centres)	Control of confounding variables
Studies that answered the systematic review questions including: prevalence of the street children phenomenon, demographic and street-related characteristics of street children and their families in Iran, and related factors of being a street child in Iran	Reliability and validity of data collection instrument and method	Appropriate measurements
		Appropriateness of statistical analyses according to study design

Methodology

We used Reference Manager 11 to delete duplicates and assigned a unique identification number to each citation. For evaluation of the feasibility of the meta-analysis, due to the insufficiency of the statistical data regarding the homogeneity of the identified findings (Khan, Kunz, Kleignen, & Antes, 2003), the homogeneity of the findings was examined by observation. The whole dataset was checked to ascertain whether or not it included studies conducted in the same year in the same centre. There was only one large study (Jangholi, 2004) whose participants (n = 1379) were all children admitted in the year 2000 to Khaneye Sabz, an indoor centre in Tehran. All findings of common variables from other smaller studies conducted in the same year and place (Jafari, 2001; Seyyed-Karimi, 2000; Vartanian, 2000) were excluded.

For the meta-analysis, after exclusion of outlier data, the size of the sample leading to each finding was considered as its weight. Then, weighted averages were calculated to assess whether the findings were sufficiently homogeneous. In the case of significant heterogeneity, the findings were grouped into subcategories – a known method for approaching the heterogeneity of data (Khan et al., 2003): data extracted from outdoor and indoor centres, and data from Tehran and other provinces. The reason for dividing the studies between those conducted on outdoor and indoor centres was their different admission policies. For example, the admittance of non-Iranian, mainly Afghan, children is restricted in most indoor centres (Vameghi, Sajjadi, & Rafiey, 2010). Segregating the studies conducted in Tehran from those in other provinces was based on a well-known difference between the socio-economic characteristics of Tehran as the capital city and other parts of the country. Then, if the subgrouped data had enough homogeneity, they were meta-analysed; and if not, a narrative review was conducted.

Based on the search strategy, 1844 studies were identified; of these, 1783 studies were excluded based on inclusion and exclusion criteria. After assessing the qualities of the remaining 61 studies, 40 studies (21 of them descriptive and 19 analytical) were included (Affairs Deputy of Welfare Organization, 2000; Ahmad-Khaniha, 2002; Ahmadi-Khoyi, 2004; Alavi-Nia, 2005; Arezoomandi, 2003; Ebrahimi, 2003; Ehsani-Kalkhoran, 2004; Fallah, 2008; Fazelzadeh-Dinan, n.d.; Feizi, 2003; Ghasemzadeh, 2003; Gholamipour, n.d.; Golpazir-Sorkheh, 2005; Hadian, 2005; Hoseini, 2005; Jangholi, 2004; Jafari, 2001; Jafari-Sadehi & Edalatkhah, 2008; Kamrani-Fakoor, 2006; Kashani, 2007; Kashefi-Esmaeelzadeh, 2000; Kazemi, 2003; Khuzestan Bureau of Prisons & Penitentiaries, 1999; Maghsoodi, 2003; Mehdizadeh, 2002; Nosrat-Nezami, 2001; Saleh, 2000; Salmani-Barugh, 2003; Selki, 2003; Sharifi, 2004; Social Affairs Deputy of Welfare Organization of Hormozgan Province, 2003; Social Affairs Deputy of Welfare Organization of Markazi Province, 2003; Social Seyyed-Karimi, 2000; Vahdani, 2006; Vartanian, 2000; Welfare Organization of Tehran Province, 2001, 2004; Yavari, n.d.; Zandi-Mehr, 2001; Zarvari, 2005). Low quality convinced us to reject the analytical results of 15 studies, and only their descriptive parts along with the analytical results of just four studies were used. Although all of the analytical studies were case–control in design, just one of them reported an odds ratio. The publishing dates of all the documents, including eight articles, eight research reports and 24 theses, were from 1999 to 2007. The places of studies were Tehran (27 studies), Mashhad (two studies) and other cities (eight studies, i.e. Isfahan, Qom, Kermanshah, Arak, Ahvaz, Bandarabbas, Urmiah, and an unknown city of Gilan Province). An additional two studies were undertaken in more than one city: one in Tehran and Roodehen, and the other in Bandar Turkmen and Gonbade Kavoos. Also, one study was undertaken in the five cities of Tehran, Mashhad, Shiraz, Ahvaz and Rasht.

The studies were subgrouped into two main categories according to places of access to children: those accessed from the streets and in open-door centres of non-governmental organisations (15 studies) and those accessed from governmental closed-door centres (18 studies). In addition, there were seven other studies conducted on children from both types of centres.

Findings

Thirty-nine studies (n = 14,946 participants) had some information regarding the disadvantages of street children. A summary of the results is shown in Table 2.

Table 2 Studied variables and their estimation.

Weighted average (%)	Sample size of meta-analysed studies (n)	Total sample size(s) (n)	Maximum frequency in studies (%)	Minimum frequency in studies (%)	Street children and family variables
29.3	8406	8406	41.8	4.5	Parents' divorce or separation
3.6	7627	7696	11	1.2	Unsupervised
18.8	4547	4547	56.7	10	Family	Family history of arrest and imprisonment
–	–	706	75	11.8	Father
–	–	537	28	0	Mother
55.8	73	620	68	7.7	Family	Family history of drug
44.4	612	880	78.3	3.4	Father	abuse
23.4	500	850	50	0.4	Mother
–	–	1703	100	4.6	Physical	History of child abuse
–	–	945	64.7	1	Mental (other than neglect)
–	–	575	36.6	4.9	Neglect
–	–	999	49.3	1.6	Sexual
–	–	4438	61.4	12.3	Depression	Child mental health
–	–	8046	6.2	1	Mental retardation
–	–	8046	31.5	9.4	Borderline IQ
–	–	152	3		Hepatitis (HBS Ag+)	Child physical health
–	–	3983	12.6		Objective health (at least one disease)
–	–	3983	25	10.5	Unfavourable subjective health
7.9	4730	4834	50	6.9	Child cigarette smoking
–	–	4847	70	1.8	Child drug abuse
–	–	5338	75	2.2	Child delinquency

Note: HBS AG+, hepatitis B virus antigen-positive.

General information

Studies showed that about 90% of street children are boys, the majority of them are over 12 years old, almost 80% are illiterate or have had less than eight years' education, and at least one-quarter of them are Afghan. Nearly 80% of children had a connection with their families, the extent of which was different (Vameghi et al, 2012).

Socio-economic situation of child and family

As elaborated more in another article (Vameghi et al, 2012), street children come from crowded, low socio-economic families. Almost one-quarter of their fathers are unemployed and the fathers of the rest are mostly engaged in low-income jobs. Both parents, basically, have low education. The majority of children (80%) are working and most of them (68.4%) work more than six hours per day.

Disadvantages

Parental divorce or separation

There were two prevalence patterns of divorce and separation of parents among street children: more than 50% (51–93.2%) in 10 studies (n = 721) and less than 50% prevalence (4.5–41.8%) in nine studies (n = 7888). There was no visible difference between these two groups regarding type of centre or city. Of 19 studies concerning the history of divorce or separation of parents (n = 8609), meta-analysis of the findings of 16 studies (n = 8406) showed that parents of 29.3% of children were divorced or separated. One study in Mashhad (Kashefi-Esmaeelzadeh, 2000) showed in a subgroup of street children (homeless children) that 53% had a history of divorce or separation in contrast to other street children (4.5%). Based on three analytical, case–control studies (Ahmadi-Khoyi, 2004; Arezoomandi, 2003; Golpazir-Sorkheh, 2005), the divorce status of parents of street children was significantly higher than their non-street counterparts (p <  0.01). Also, the first research showed that parents' divorce increases the risk of becoming a street child by 5.7 times.

Child abuse

We found 17 studies (n = 1888) that assessed this issue. Their different definitions and assessment methods made a vast heterogeneity of data, which impeded combining the results.

Although most studies reported experience of violence at children's homes, a few researchers looked at violence in the streets. Kashefi-Esmaeelzadeh (2000; n = 300) reported that some of the street children in Mashhad experienced violence by municipality (31%) and police (10%), which turned into 9% and 40%, respectively, for homeless children. Also, Arezoomandi (2003), Ahmad-Khaniha (2002) and Sharifi (2004) reported 70%, 50% and 19.5% prevalence of different types of abuse in the street, respectively.

Physical abuse

Fourteen studies (n = 1703) found some data on experience of physical violence by children basically in their homes. Although six studies reported more than 50% prevalence of physical abuse, different definitions prevented us from meta-analysing them. Describing data in centre-type-based subgroups could not explain the heterogeneity of findings either.

Mental abuse

The most diffused results belonged to the mental abuse category, with a number of definitions including verbal punishment, ignoring the child, neglecting the child's needs, exposure to parental violence, mental punishment, emotional abuse, and forcing them to work, based on nine studies. According to five studies (n = 575), up to 36.6% of children reported neglect by their parents in contrast to a maximum 64.7% frequency of other types of mental abuse found in eight studies (n = 945).

Sexual abuse

Seven studies (n = 999) looked at the occurrence of sexual abuse among street children and revealed up to 49.3% prevalence. A wide distribution of data prevented meta-analysis.

The only two studies that analysed the relationship between abuse at home and becoming a street child (that is, Arezoomandi, 2003; Kashani, 2007) showed no significant relationship between these two.

Family history of imprisonment

Of 15 studies (n = 5112) related to family history of imprisonment, meta-analysis of the findings of seven studies (n = 4547) showed that 18.8% of street children have at least one close family member with a history of arrest or imprisonment. Fathers obviously had more imprisonment history than mothers. According to Kashefi-Esmaeelzadeh (2000), the prevalence of father's arrest among homeless children was 75% versus 11.8% in non-homeless street children in Mashhad. A single study (Ahmadi-Khoyi, 2004) that assessed the association between family history of arrest and being a street child found no association.

Family history of drug abuse

Sixteen studies (n = 1380) looked at the history of drug abuse in families. Ten studies (n = 620) revealed that 7.7–68% of children have at least one family member with a drug abuse problem, notwithstanding the type of his/her relationship with the child. Meta-analysis of the findings of seven research studies (33.3–68%, n = 247) showed that 55.8% of children have a family member with a drug abuse issue. Out of all 16 studies, in eight studies (n = 850) that mentioned fathers' history of drug abuse we found 31–78.3% prevalence whose meta-analysis showed 44.4% prevalence. On the other hand, in seven studies (n = 562) mentioning mothers' history it was found that its prevalence is between 14.3 and 50%, and meta-analysis of five studies (n = 500) showed 23.4% prevalence of drug abuse history. While Ahmadi-Khoyi (2004) and Kashani (2007) confirmed a significant association (p = 0.01) between family history of drug abuse and becoming a street child, Arezoomandi (2003) did not find any association.

Child physical health

Seven studies (n = 4922) had some findings regarding the physical condition of children.

Hepatitis and HIV tests

Vahdani (2006) and Fallah (2008) both reported a 3% frequency of positive hepatitis B virus surface antigen, and Fallah (2008) also showed a 5.3% frequency of positive Hepatitis C virus antibody. All of the positive hepatitis B virus surface antigen and hepatitis B virus surface antibody cases in two studies were boys. The single study on HIV (Vahdani, 2006) reported no cases of positive HIV among children.

Physical disability

Kashefi-Esmaeelzadeh (2000) reported some type of physical disability among 12.5% of homeless children and 4.5% of non-homeless children.

Objective health

The only study that had data on children's physical health based on their physical examination involved 3983 children (Social Affairs Deputy of Welfare Organization, 2000) who were admitted to the centres of welfare organisation all over the country. Accordingly, 12.6% of children had at least one disease, of which the most prevalent were dermatological (31.6%), internal (11.9%) and musculoskeletal (9.1%) diseases. In addition, 24% of children had malnutrition and just 25% were completely vaccinated.

Subjective health

Two studies (n = 386) assessed the subjective health of children. In a study in Mashhad (Kashefi-Esmaeelzadeh, 2000), 25% of homeless children and 12.7% of non-homeless street children reported no good physical health. Another study (Jafari-Sadehi & Edalatkhah, 2008) in Gilan province showed that 10.5% of children describe their condition as bad.

Child mental health

Of nine studies (n = 8917) that described the psychological situation of children, four studies assessed the presence of depression and suicide using different scales and reported varying results. Also, four studies (n = 8514) measured the Intelligence Quotient (IQ) of children and the prevalence of mental retardation.

Depression

One study by the Social Affairs Deputy of Welfare Organization (2000; n = 2527) reported the prevalence of depression using the Eysenck inventory as 12.3% in welfare organisation centres in all provinces. There were two studies conducted in Tehran: Ghasemzadeh (2003) found a 45% prevalence of depression based on interviews with children, and Ahmad-Khaniha (2002), using Kids Schedule for Affective Disorders and Schizophrenia, found a 61.4% history or presence of depression (86.7% of girls and 48.2% of boys). One study in Qom (Gholamipour, n.d.) reported 6.3% suicide attempts among street children.

Intelligence Quotient

The most frequent IQs of children in three studies (Jangholi, 2004; Saleh, 2000; Social Affairs Deputy of Welfare Organization, 2000) were medium IQ (43.4%), 85–105 IQ (42%) and 80–90 IQ (43%), respectively, which all revealed approximately normal IQ (85–105). At the same time, the frequency of intellectual disability (IQ <  70) was 1%, 6.2% and 3.3%, respectively, but the frequency of borderline IQ (70–85) was 9.4%, 31.5% and 26.6%. Regarding psychological problems of children, Ghasemzadeh (2003) showed that 50–90% of children had a variety of symptoms such as a feeling of inferiority, agitation and instability, tendency to revenge and violence, distrust, anxiety, insecurity, identity problems and difficulty in concentration. Also, Salmani-Barugh (2003) reported that more than 80% of street children had negative self-concepts.

Child cigarette smoking and drug abuse

Eight studies (n = 4663) revealed 6.9–50% prevalence of cigarette smoking among children. The least prevalence related to the Social Affairs Deputy of Welfare Organization (2000) study and the highest belonged to children from an open-door centre in Tehran (Yavari, n.d.). It seems that in four studies with girls among their participants (Ahmad-Khaniha, 2002; Fallah, 2008; Sharifi, 2004; Social Affairs Deputy of Welfare Organization, 2000), the rates – that is, 16.1%, 6.7%, 14.3% and 13% respectively – were lower than other studies. Seven studies (n = 4730) showed that 7.9% of children were smokers.

Also, 11 studies (n = 4847) that looked for drug use in children reported 1.8% (Social Affairs Deputy of Welfare Organization, 2000) prevalence of drug use in welfare centres to 70% (Hadian, 2005) in a street sample of Tehran and Roodehen. We observed a wide difference between homeless and non-homeless street children in Mashhad (34.4% versus 4.1%) and lower rates of drug abuse in girls-included studies, which reported drug use prevalence as 9.1%, 1.8% and 4.3% (Ahmad-Khaniha, 2002; Sharifi, 2004; Social Affairs Deputy of Welfare Organization, 2000), respectively. Because of the non-homogeneity of data, we dismissed meta-analysis. Children may use such drugs as opium, heroin, cannabis, marijuana, alcohol, glue and pharmaceuticals. The most prevalent substances varied in different studies: it was cannabis (63.3%) in homeless children according to Kashefi-Esmaeelzadeh (2000), heroin (46%) in a closed-door centre in Tehran (Nosrat-Nezami, 2001), and alcohol (72%) among non-homeless children in the study by Kashefi-Esmaeelzadeh (2000). The only study that assessed the relationship between drug use and being street children (Arezoomandi, 2003) found no significant difference between street and non-street groups.

Child delinquency

Eleven studies (n = 5338) reported a 2.2–75% history of delinquency among children; both percentages referred to non-homeless and homeless street children in Mashhad. Zandi-Mehr (2001) reported a 46% prevalence of delinquency in Tehran, and the Social Affairs Deputy of Welfare Organization (2000) study showed that 17.2% of children from welfare centres around the country had a history of delinquency. Because of the wide heterogeneity, we decided not to combine the findings. In a few studies, types of delinquencies were mentioned, including stealing (0.7–17.4%), sex work (2.3%), fighting (6%), and drug use and dealing (41.3%).

Discussion

Based on our systematic review, we can see that street children in Iran are confronted with a series of disadvantages in their hard day-to-day lives. While it seems that some of these unpleasant situations, like their parents' divorce, living in a house with an addicted family member, involvement of parents in crime and being mentally and physically abused by them, along with poverty and the necessity to acquire income, are pushing the children onto the streets, their other miseries are probably the result of living and working on the street. Obviously, many of them are physically ill, some are depressed, some are involved with drugs and delinquency, and many are exposed to violence on the streets.

Street children in Iran belong to a low socio-economic class (Vameghi et al, 2012) and therefore it is highly suspected that most of them are on the street to help themselves and their families survive. Meanwhile, the high percentage of their parents' divorce and separation (29.3%), along with the high frequency of drug abuse (59.8%) and violence in their families, suggest that both mechanisms of poverty and adverse familial conditions prepare children to leave their homes for the streets as a way to solve their problems.

The results of our study regarding the familial disadvantages of street children are consistent with reports from many other countries: Ward & Seager (2010) in South Africa; Ribeiro & Ciampone (2001) in Brazil; Aptekar (1994) in India and Colombia; World Food Program and United Nations Children's Fund, United Nations Office for Drug Control and Crime Prevention (2001) in Egypt; and Hong & Ohno (2005) in Vietnam.

According to a large review of street children studies, there is a complex and multifaceted aetiology for ‘street-connectedness’, so that ‘deprivation of close, supportive and loving relationships with adult caregivers … together with domestic violence, mental health, alcohol and substance abuse problems of parents’ have key roles as ‘catalysts’ for their leaving home (Benitez, 2011).

While there is too much evidence that shows children, as a whole, are experiencing a mixture of poverty (UNICEF, 2005), disrupted families and domestic violence (UNICEF, 2007) all around the world, it seems that when these disadvantages are accumulated to a level beyond their resilience they leave home to rid themselves of their unpleasant situation, but on the streets they may experience again a dual harm that, in the context of their inability to access educational resources, the lack of leisure and happiness, lack of physical and mental health, and absence of normal relationships with the wider community, can push them more to the margins and make children more vulnerable to poverty, violence and other social problems.

The findings of this study must be treated with caution because of some limitations. An important one is the design of the study, which does not permit us to definitely conclude an aetiological or outcome relationship between variables. In addition, the diversity of definitions, heterogeneity and imperfect reports inhibited combining and meta-analysing some of the various data. Therefore we propose more rigour in designing future studies in order to achieve a precise understanding of the role of familial conditions on the street-connectedness of children or the outcomes of living and working on the streets. This is particularly recommended for important factors such as addiction and HIV/AIDS, for which we have had the least combinable information based on studies. Finally, most of our studies were theses that have not been reviewed. However, we tried to resolve this by carrying out critical appraisal of all studies.

Although it seems that socio-economic factors are important risk factors for the street-connectedness of children in Iran, a number of street children run away from painful situations in their homes. Since one of the main purposes of systematic reviews is collecting and combining scientific documents to be used by decision-makers, the findings of this study show the necessity of social policies regarding the support of street children and their families that could be used by related organisations.

It seems that reducing parental conflicts, approaching the involvement of parents with drugs and crime, reducing children's abuse and treating their physical illness and depression can reduce the burden of this problem. In addition, facilitating their access to education, leisure and happiness and healthcare, and a rich relationship with the wider community, can increase their resilience.

Additional information

Notes on contributors

Meroe Vameghi

Meroe Vameghi, MD (psychiatrist), University of Social Welfare and Rehabilitation, Social Determinants of Health Research Center, assistant professor. Research areas: Child Labor, Domestic Violence, and Social Determinants of Health.

Hassan Rafiey

Hassan Rafiey, MD, MPH, University of Social Welfare and Rehabilitation, Research Department of Social Welfare, assistant professor. Research areas: Drug Abuse Prevention, Social Deviance, Social Health, Social Determinants of Health.

Homeira Sajjadi

Homeira Sajjadi, MD, MPH, University of Social Welfare and Rehabilitation, Research Department of Social Welfare, assistant professor. Research area: Social Determinants of Health

Arash Rashidian

Arash Rashidian, MD, PhD, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, associate professor.

Notes

^1. See www.Irannamaye.org

^2. See Irandoc.ac.ir, www.iranmedex.com, www.sid.ir, www.magiran.com, http://iranpsych.tums.ac.ir/www.nlai.ir, http://spdb.uswr.ac.ir/, http://TAKchildren.com