Public Health Nursing Vol. 32 No. 1, pp. 87–89 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12116
REVIEW SUMMARIES Summaries of systematic reviews on public health nursing-related issues from the Cochrane Library, Cochrane Nursing Care Field, and other evidence review organizations A FIELD OF
THE COCHRANE COLLABORATION®
Interventions for Promoting Reintegration and Reducing Harmful Behavior and Lifestyles in Streetconnected Children and Young People Barbara Ritzert, Ph.D., R.N., and Member of the Cochrane Nursing Care Field (CNCF) Nursing, Texas Christian University, Fort Worth, Texas Correspondence to: Barbara Ritzert, Nursing, Texas Christian University, Fort Worth, TX. E-mail: [email protected]
Review Question What are the effects of interventions compared with service as usual in drop-in centers or shelters to promote reintegration and reduce harms in streetconnected children and young people?
Keywords: interventions, reintegration, street children, agriculture, street youth.
Type of Review This is a summary of a Cochrane systematic review of eleven randomized or quasi-randomized studies. Data from eight of eleven studies meeting inclusion criteria were appropriate for meta-analysis, with description of the three remaining studies presented in narrative format.
Relevance for Public Health Nursing The prevalence of street-connected children and young people (defined as children meeting any combination of the following descriptors: children and
young people who may live and work on the street or in public spaces, and/or they may return to family homes or hostels at night for any period of time or different time period) is increasing on a national and global level. Although there are varied degrees of resiliencies developed over time in this population, they are at risk for a range of unhealthy behaviors and poor lifestyle choices, excluding many from mainstream support systems, educational opportunities, and choices promoting the long-term potential for reintegration and success in society. Mediating factors predisposing children and youth to street life in high-income countries are commonly associated with breakdown of the family unit and parental abuse; whereas, factors contributing to this social phenomenon in middle- and low-income countries are more diverse including additional factors associated with war and migration. Poverty, abuse, and dysfunctional home life appear to be common themes across all economic environments; thus the need to identify effective interventions for a variety of contexts is foundational to the promotion of reintegration and reduction in harmful behaviors.
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Number 1
Characteristics of the Evidence A total of 2,315 study participants were recruited from shelters, hostels, community-based organizations, street outreach centers agencies, or by “word of mouth”. Participants were aged from 3 to 23 years (age specifications for the review were 0–24 years) who received service as usual (SAU) and/or specialized interventions in the drop-in center or shelter setting. Interventions were compared to a different type of intervention, no intervention, or standard practice interventions. The control group was derived from shelters and hostels providing similar models of service as usual to the environments from which the intervention population was recruited. The primary outcomes of interest were harm reduction and reintegration. Reintegration was defined as children and young people entering a residential or educational environment with the potential to provide elements of physical safety, nutrition, medical care, education, and counseling to facilitate recreation, social, and economic opportunities, as well as personal and spiritual growth to enhance chances for long-term life. Harm reduction was used as a broad based term to describe interventions targeted to address harms associated with lifestyles or street-connected young people such as substance abuse and risk taking sexual behavior. All studies were drawn from high-income countries, primarily the Unites States, with one study from the United Kingdom and one study from Korea. Specialized interventions were based on therapeutic models of social, emotional, cognitive, behavioral, and systematic orientation. Interventions included a broad range of participation and duration from single sessions to “on-going” therapy. In addition, some interventions were multicomponent in nature including external service providers, or interventions delivered in a peer or family group setting. Overall, the authors evaluated the quality of the available evidence in the eleven studies meeting inclusion criteria to be “moderate”. Most studies were considered low risk of selection bias, and four studies were regarded at low risk of detection bias due to blinding of outcome assessors. Due to the nature of the intervention, blinding of participants or personnel was not possible, and all studies were, therefore, rated at high risk of performance bias.
January/February 2015
Reintegration, the primary outcome, was not measured in any of the studies. However, secondary outcomes associated with sexual health, substance use risk behaviors, self-esteem, depression, use of violence, and contact with family members were reported. Studies measuring outcomes in similar manners were analyzed using a random-effects model analysis of mean difference (MD). When different scales were used to measure the same or similar outcome, the effect size was calculated using a random-effects model analysis of standardized mean difference (SMD). In addition to meta-analysis, the authors calculated change scores for outcome items included and excluded from the meta-analysis to serve as indicators of a potential change resulting from SAU or specialized interventions. Outcome analysis yielded mixed or inconclusive results, with most outcomes resulting in a positive change or improvement from baseline in both intervention and comparison groups, indicating outcomes are similar across intervention and control groups. However, due to limitations of mixed methodologies between studies and confounding factors such as cointerventions of usual care, external interventions, and special interventions not fully described in the primary study design, the authors concede caution in drawing this conclusion. Another substantial limitation of the studies was the absence of the comparator “no service”, a universal condition experienced by most street-connected children and young people, regardless of the economic status of the country. Overall, the results of the secondary outcomes measuring safer or reduced sexual activity were not of statistical significance, with varying changes in behavior across different time periods in both the intervention and control groups (Number of times had sex in the last 90 days: MD 0.04, 95% Confidence Interval (CI) 0.22 to 0.13; and Number of sexual partners in the last 90 days: MD 0.73, 95% CI 2.97 to 4.43). Outcomes addressing safe or reduced substance use were deemed to be uncertain and of mixed direction, representing a wide range of measurements and reference points, none of which reached statistical significance. Analysis of data measuring self-esteem (SMD 0.11, 95% CI: 0.22 to 0.44) and depression (MD: 0.43, 95% CI: 2.83 to 1.98) also failed to demonstrate a benefit reaching statistical significance between the intervention and comparator groups.
Ritzert • Reintegration for street-connected youth There were no statistically significant effects indicating a reduced effect on verbal aggression (MD: 0.00, 95% CI: 0.07 to 0.06), family violence (MD: 0.00, 95% CI: 0.02 to 0.02), or increased contact with family (MD: 9.46, 95% CI: 27.96 to 9.03).
Implications for Population-Based Research ● Evidence was extremely mixed and inconclusive, failing to reach statistical significance in any outcomes; therefore, no recommendations for practice can be drawn regarding effectiveness of special interventions compared with SAU in a drop-in center or shelter setting, to promote reintegration or reduction in harmful behavior in street-connected children and young people. ● It is noteworthy that both the intervention and SAU pointed toward a positive trend in some outcomes, therefore, a structured approach may be of some benefit in itself.
Implications for Public Health Nursing Research ● Inconclusive evidence from this review to inform clinical practice emphasizes the need for further research in this area derived from controlled trials with consistent intervention and outcome
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measures to provide a significant pool of homogeneous data for analysis. ● High quality study designs based on theoretical frameworks, standardized evaluation scales, and tools for outcome measures would strengthen the ability to evaluate interventions across multiple types of shelter environments that may be beneficial to street-connected children and youth. ● Studies focused on strategic interventions to address the universal underlying themes of poverty, abuse, and dysfunctional family environments would serve to inform practice across all income level (low, middle, and high) countries. ● Studies focused on strategic interventions to identify culturally sensitive and gender specific risk factors would provide a basis for intentionality in the development of services to promote reintegration that are need specific to street-connected children and young people seeking shelter.
Reference Coren, E., Hossain, R., Pardo Pardo, J., Veras, M. M. S., Chakraborty, K., Harris, H., & Martin, A. J. (2013) Interventions for promoting reintegration and reducing harmful behavior and lifestyles in street-connected children and young people. Cochrane Database of Systematic Reviews, 2. Art. No.: CD009823. doi:10.1002/14651858.CD009823.pub2.
REVIEW SUMMARIES Summaries of systematic reviews on public health nursing-related issues from the Cochrane Library, Cochrane Nursing Care Field, and other evidence review organizations A FIELD OF
THE COCHRANE COLLABORATION®
Interventions for Promoting Reintegration and Reducing Harmful Behavior and Lifestyles in Streetconnected Children and Young People Barbara Ritzert, Ph.D., R.N., and Member of the Cochrane Nursing Care Field (CNCF) Nursing, Texas Christian University, Fort Worth, Texas Correspondence to: Barbara Ritzert, Nursing, Texas Christian University, Fort Worth, TX. E-mail: [email protected]
Review Question What are the effects of interventions compared with service as usual in drop-in centers or shelters to promote reintegration and reduce harms in streetconnected children and young people?
Keywords: interventions, reintegration, street children, agriculture, street youth.
Type of Review This is a summary of a Cochrane systematic review of eleven randomized or quasi-randomized studies. Data from eight of eleven studies meeting inclusion criteria were appropriate for meta-analysis, with description of the three remaining studies presented in narrative format.
Relevance for Public Health Nursing The prevalence of street-connected children and young people (defined as children meeting any combination of the following descriptors: children and
young people who may live and work on the street or in public spaces, and/or they may return to family homes or hostels at night for any period of time or different time period) is increasing on a national and global level. Although there are varied degrees of resiliencies developed over time in this population, they are at risk for a range of unhealthy behaviors and poor lifestyle choices, excluding many from mainstream support systems, educational opportunities, and choices promoting the long-term potential for reintegration and success in society. Mediating factors predisposing children and youth to street life in high-income countries are commonly associated with breakdown of the family unit and parental abuse; whereas, factors contributing to this social phenomenon in middle- and low-income countries are more diverse including additional factors associated with war and migration. Poverty, abuse, and dysfunctional home life appear to be common themes across all economic environments; thus the need to identify effective interventions for a variety of contexts is foundational to the promotion of reintegration and reduction in harmful behaviors.
87
88
Public Health Nursing
Volume 32
Number 1
Characteristics of the Evidence A total of 2,315 study participants were recruited from shelters, hostels, community-based organizations, street outreach centers agencies, or by “word of mouth”. Participants were aged from 3 to 23 years (age specifications for the review were 0–24 years) who received service as usual (SAU) and/or specialized interventions in the drop-in center or shelter setting. Interventions were compared to a different type of intervention, no intervention, or standard practice interventions. The control group was derived from shelters and hostels providing similar models of service as usual to the environments from which the intervention population was recruited. The primary outcomes of interest were harm reduction and reintegration. Reintegration was defined as children and young people entering a residential or educational environment with the potential to provide elements of physical safety, nutrition, medical care, education, and counseling to facilitate recreation, social, and economic opportunities, as well as personal and spiritual growth to enhance chances for long-term life. Harm reduction was used as a broad based term to describe interventions targeted to address harms associated with lifestyles or street-connected young people such as substance abuse and risk taking sexual behavior. All studies were drawn from high-income countries, primarily the Unites States, with one study from the United Kingdom and one study from Korea. Specialized interventions were based on therapeutic models of social, emotional, cognitive, behavioral, and systematic orientation. Interventions included a broad range of participation and duration from single sessions to “on-going” therapy. In addition, some interventions were multicomponent in nature including external service providers, or interventions delivered in a peer or family group setting. Overall, the authors evaluated the quality of the available evidence in the eleven studies meeting inclusion criteria to be “moderate”. Most studies were considered low risk of selection bias, and four studies were regarded at low risk of detection bias due to blinding of outcome assessors. Due to the nature of the intervention, blinding of participants or personnel was not possible, and all studies were, therefore, rated at high risk of performance bias.
January/February 2015
Reintegration, the primary outcome, was not measured in any of the studies. However, secondary outcomes associated with sexual health, substance use risk behaviors, self-esteem, depression, use of violence, and contact with family members were reported. Studies measuring outcomes in similar manners were analyzed using a random-effects model analysis of mean difference (MD). When different scales were used to measure the same or similar outcome, the effect size was calculated using a random-effects model analysis of standardized mean difference (SMD). In addition to meta-analysis, the authors calculated change scores for outcome items included and excluded from the meta-analysis to serve as indicators of a potential change resulting from SAU or specialized interventions. Outcome analysis yielded mixed or inconclusive results, with most outcomes resulting in a positive change or improvement from baseline in both intervention and comparison groups, indicating outcomes are similar across intervention and control groups. However, due to limitations of mixed methodologies between studies and confounding factors such as cointerventions of usual care, external interventions, and special interventions not fully described in the primary study design, the authors concede caution in drawing this conclusion. Another substantial limitation of the studies was the absence of the comparator “no service”, a universal condition experienced by most street-connected children and young people, regardless of the economic status of the country. Overall, the results of the secondary outcomes measuring safer or reduced sexual activity were not of statistical significance, with varying changes in behavior across different time periods in both the intervention and control groups (Number of times had sex in the last 90 days: MD 0.04, 95% Confidence Interval (CI) 0.22 to 0.13; and Number of sexual partners in the last 90 days: MD 0.73, 95% CI 2.97 to 4.43). Outcomes addressing safe or reduced substance use were deemed to be uncertain and of mixed direction, representing a wide range of measurements and reference points, none of which reached statistical significance. Analysis of data measuring self-esteem (SMD 0.11, 95% CI: 0.22 to 0.44) and depression (MD: 0.43, 95% CI: 2.83 to 1.98) also failed to demonstrate a benefit reaching statistical significance between the intervention and comparator groups.
Ritzert • Reintegration for street-connected youth There were no statistically significant effects indicating a reduced effect on verbal aggression (MD: 0.00, 95% CI: 0.07 to 0.06), family violence (MD: 0.00, 95% CI: 0.02 to 0.02), or increased contact with family (MD: 9.46, 95% CI: 27.96 to 9.03).
Implications for Population-Based Research ● Evidence was extremely mixed and inconclusive, failing to reach statistical significance in any outcomes; therefore, no recommendations for practice can be drawn regarding effectiveness of special interventions compared with SAU in a drop-in center or shelter setting, to promote reintegration or reduction in harmful behavior in street-connected children and young people. ● It is noteworthy that both the intervention and SAU pointed toward a positive trend in some outcomes, therefore, a structured approach may be of some benefit in itself.
Implications for Public Health Nursing Research ● Inconclusive evidence from this review to inform clinical practice emphasizes the need for further research in this area derived from controlled trials with consistent intervention and outcome
89
measures to provide a significant pool of homogeneous data for analysis. ● High quality study designs based on theoretical frameworks, standardized evaluation scales, and tools for outcome measures would strengthen the ability to evaluate interventions across multiple types of shelter environments that may be beneficial to street-connected children and youth. ● Studies focused on strategic interventions to address the universal underlying themes of poverty, abuse, and dysfunctional family environments would serve to inform practice across all income level (low, middle, and high) countries. ● Studies focused on strategic interventions to identify culturally sensitive and gender specific risk factors would provide a basis for intentionality in the development of services to promote reintegration that are need specific to street-connected children and young people seeking shelter.
Reference Coren, E., Hossain, R., Pardo Pardo, J., Veras, M. M. S., Chakraborty, K., Harris, H., & Martin, A. J. (2013) Interventions for promoting reintegration and reducing harmful behavior and lifestyles in street-connected children and young people. Cochrane Database of Systematic Reviews, 2. Art. No.: CD009823. doi:10.1002/14651858.CD009823.pub2.
