Sexual risks , Substance abuse and Protective factors among , Kampala Street and slum children

*Correspondence: Dr. Rogers Kasirye, Executive Director, Uganda Youth Development Link Po Box 12659, Kampala Uganda. Tel: +256414 530353; Hubert H. Humphrey Fellow 2011-12; Virginia Commonwealth University, U.S; (Website: http://www.uydel.org/); E-mail address: kasiryer@yahoo.com Dr. Rogers Mutaawe, Senior Programme Manager, Uganda Youth Development Link Po. Box: 12659, Kampala Uganda. Tel: +256414530353; Hubert H. Humphrey Fellow 2015-16; Virginia Commonwealth University, U.S; E-mail address: mutaawe2@gmail.com


Introduction
The street children phenomenon is a global and regional problem.Poverty, family breakdown, child abuse and neglect are the leading causes of the problem.In Egypt for instance, families which are economically marginalized have become seriously dysfunctional and have placed their children in circumstances that have resulted in such youth leaving their homes and trying to survive in the often unprotected and hazardous street milieu 1 .
Likewise, substance abuse among young people in Uganda has been recognized as one of the major causes of mental health risks 2,3 .Anecdotal evidence reveals that substance abuse has increased over the years among young people and may have increased in terms of proportion, population and also in area/coverage.Alcohol use in Uganda raises particular concern.According to World Health Organization (WHO) in 2005 4 the country had the highest per capita consumption worldwide.While, Uganda serves as a model for Africa in the fight against HIV and AIDS because of the strong engagement and prevention efforts, transmission remains high young slum and street population with an incidence rate of 15.5% compared to the national average of 7.3% 5 .Several studies in HIV AIDS and young people in Uganda have tried to link sexual behavior to HIV/AIDS mode of transmission, but little do we read explaining in detail the prediction of substance abuse and high sexual risk behavior among street and slum youth.
Substance abuse as a problem also remains largely un-addressed yet it gives rise to sexual risk behaviors such as inconsistent condom use, having multiple partners and early sexual involvements as a major health concern 6 .Increasingly, in Uganda, sexual risk among adolescents has been documented 7,8,9,10 .In Uganda, no record has been documented substantially through a research about the highly risky sexual behavior and its relationship to substance abuse among the slum youth population.In 2005, Uganda was ranked as number one in the world with serious alcohol abuse and also has a high rate of teenage pregnancy at 25% 11 .There is a dearth of information regarding the specific mental health needs and concerns among street youth in sub-Saharan Africa, but it is expected that youth who live on the streets and in the slums have the highest levels of suicidal ideation and behavior 2 .
The study findings also give insights in the predictors of early sexual and substance abuse involvement, as a key to improving interventions serving these populations.This article describes sexual risk behaviors and substance abuse in a sample of 203 street and slum youth, aged between 14-24 years who were seeking assistance or those already enrolled in the program at Uganda Youth Development Link (UYDEL) facilities, all of whom are strictly out of school youth.

Population setting
UYDEL operates 8 drop-in Centres/safe spaces across Kampala City, Uganda.All these centres participated in the recruitment and survey administration.Drop in centres are rented houses by UYDEL which serve as safe spaces for recruitment, screening, assessment and service centres for marginalized and vulnerable young people residing in slum areas.They are located in Nakawa, Kawempe, Rubaga, Central and Makindye divisions, Kampala district.The primary beneficiaries are street children, slum youths, sexually exploited young girls, drug abusing youths, and the unemployed and homeless young people.Each drop in centre has at least 3 social workers and an average of 5 vocational skills instructors.The social workers do the initial screening of the young people; provide counseling and psychosocial support; conduct home visits, oversee vocational skills livelihood training and job placement.
At each centre, 2 social workers (hereinafter referred to as interviewer) were recruited and trained for data collection.Slum, street children and orphans are persons who have not yet attained the legal age of 18 years.The slum and street youth do not have a stable home, may or may not have any current interaction with parents/guardians, and may also be facing abusive situations in their home environments.Since family background characteristics (including past abuse) are part of the issues on the survey questionnaire, it was not feasible to ask parent/caretakers to give permission for the youth to participate in the study.
Interviews were completed with 203 street and slum youth (61 males and 142 females between the ages of 14-24 years) out of 350 youth registered at the UYDEL Centre.The 147 young people were excluded because clients were given choice of no participation through seeking informed consent before the interviews.The young people that did not want to participate were exempted from the study.The majority of youths covered were 15-18 years and were seeking assistance at the youth drop in centres or at the main rehabilitation centre of the UYDEL.During the process of consent, the young people were assured that non participation in the survey would not in any way victimize them or affect their chances of receiving services at the centre.

Training of researchers
The interviewers underwent training in interviewing including research ethics required for such a survey.The interviews were held at UYDEL facilities and drop in centres.Each interviewer recruited potential study participants among attendants at the specific drop-in Centre.All the children and youth between 14-24 years were eligible to participate in the study.No exclusion criteria were implemented beyond the age range.They were recruited by speaking to each individual and seeking their consent to participate in the study.The interviewers read the consent form to each individual and obtained an indication of the child's willingness to participate in the study.Each interviewer kept a record of those approached for participation (initials only) to make sure potential participants are not recruited more than once and also to assess the overall participation rate for the survey.The interviewers had experience in handling stress and traumatic situations and providing support to individual participants during interviews.

Data collection methods
The study employed a face to face anonymous interview lasting 25-30 minutes using a structured questionnaire.The survey questions addressed three key areas sexual risky behaviors, substance abuse and employment.
Prior to the execution of the study, clearance was obtained from the Uganda National Council for Science and Technology (a National Institutional Review Board).All necessary steps were taken to ensure that all the standards of administering research to human subjects were adhered to.A waiver for parental consent was sought for participants below 18 years who fend for their livelihood, which is part of the definition of street and slum children and youth.

Social demographic characteristics of the street and slum youths
In terms of social demographic characteristics, Table 1 reveals that almost 50% of the study sample was below 18 years.The female representation was three to one male.About half of both males and females had one of their parent dead, 28 percent dropped out of school after primary seven; they never continued with secondary education.53 percent and 40 percent of youth (girls and boys) were trafficked and boys were more likely already employed in odd jobs in the markets and slums.Data revealed that boys on the contrary, were more likely to be homeless.

Sexual risky behavior
In terms of sexual risky behavior, the results showed that 70 percent of the street and slum youth had sexual debut before the age of 15 years.17 percent of study participants had a history of forced sex.A small number of only 23 percent were abstaining from sexual acts.Exchange of sex for money, goods, or services was five times more among females than male youth probably a sign of engaging in multiple sex partners.
Among those sexually active, the average number of sexual partners one engaged with per day were three.
Condom use as a method of protection was around 42 percent, meaning that many of those who were sexually active engaged in risky unprotected sex.
The results also revealed that girls were at higher risk of engaging in risky sexual behavior with almost 70 percent of all children especially girls had exchanged sex for goods, services and money and used alcohol.Exchange of goods, services for sex had become a survival norm and pointing to a negative coping mechanism and bad peer networks.The results also indicated that 60 percent of girls discuss safe sex with partners and 81 percent of girls were more likely to use drugs during sexual episodes.
The number that could mention condoms and other fertility awareness based methods was as low as 14 percent.Girls test for HIV more often (60 percent in 3 months) and almost half do not pick their HIV results.The demographics also show that many of the street and slum children had never known their families.Others came from poor families and had lost either a single or both parents indicating lack of parental guidance.

Substance abuse
In terms of substance abuse, about half the youth had used drugs including alcohol, drugs and tobacco.Boys were more likely to have used drugs or alcohol and ever tried cigarette smoking.Among females, alcohol use was more used during sexual episodes (45%).Significant levels of using alcohol were found to play a significant role for slum girls for either engaging in survival sex, or helping to cope with traumatic events or homelessness.

Street and slum youth sexual risky behavior
Street and slum youth sexual risky behavior is one of the leading risk factors in HIV transmission including having multiple partners, casual and unprotected sex.The HIV transmission rates found for this population may or may not be significantly different from those found in the same age group who are not members of the "street and slum" subpopulation.Having sex under the influence of alcohol or drugs exacerbates the situation and can compromise use of condoms and heighten sexual risks including HIV/AIDS among others.Though girls were most likely to discuss or suggest a condom to a partner, surprisingly almost the same numbers were willing to go on for unprotected sex.What is more surprising is that the girls having unprotected sex were a percentage higher and very likely to have had engaged a sexual activity under the influence of drugs.Many girls reportedly exchanged sex for money, goods, or services.Girls are more likely to have had an HIV test in the past 3 months than to discuss safe sex with partners.Survival and exchange of sex by the slum youth comes with challenges of rape (17%) and coercion into sexual acts beyond their measure.It can leave many youth mentally broken, psychologically and socially devastated while repetitive sexual assaults and exposure have dire consequences on the survivors and other psychological problems.
In spite of the regular frequency of voluntary counseling and HIV testing, involvement in highly risky sexual behavior is still going on.The problem of sexual risk and use of substances appears to go beyond the normal message delivery and volunteer counselling and testing but rather understand and improve the protective factors and adapt new innovations such as motivational interview and brief interventions that help young people deal with multiple risks.
In spite of the low numbers of boys interviewed, this group was more likely to have used drugs or alcohol and to have ever tried cigarette smoking.Youth will continue to engage in high risk sexual activities in and outside the family because of many unmet emotional (stress loss and grief), physical and economical needs.Over 50 percent had separated at an early age and the same number had dropped out before secondary education and the limited survival opportunities in the city slums.
The drop in centres serve more females compared to boys because according to interactions with the social workers it was proposed that this maybe because of their vulnerability and girls easily seek support services faster compared to the boys.
Parental guidance is a significant factor and plays a positive supportive role in helping such slum youth to shape their behavior, positively solve problems, deal with survival and other traumatic experience.This maybe because the family and its environs are key in conducting and reframing the slum youth mindset on how to deal with their problems including sex and use of drugs in their adolescent lives.Living independently in the slums may heighten easy access to and use of cheap alcohol and drugs which eventually may lower self-control and increase likelihood for risky sexual activities without use of condoms.Many of these girls reported being highly sexually active with frequent use of alcohol and engagement with many partners in their early age.

HIV testing and risky sexual behavior
Implementing HIV/AIDS testing and behavior programs alone appears to have a limited effect on street and slum youth lives as there appears to be many other social determinants that affect their sexual life style.Many youth still engage in unsafe and risky sexual behavior involving use of drugs and get involved with multiple partners.There is need to increase positive survival and vocational livelihood skills through training and creating employment opportunities for economic emancipation in order to deal with the vulnerability leading to sexual risk and exploitation.There is need to make condoms more available and the information that goes with it in order to improve access in  this sub-population.Increasing HIV testing opportunities to make it more robust and readily available at individual level settings is urgent.Use of social media tools including cellphones to communicate, strengthening and sustaining youth healthy behaviors through new motivational approaches to reduce drugs and high sexual risks.Many of the unmet psychosocial needs including trauma, and stress need urgent attention amongst this population.

Study limitations
One limitation is that the study on sexual risk, substance abuse among street and slum youth was discussed in context of entry to the program.The study did not conduct focus group discussions to be able to get more qualitative data.We only reported on 203 street youth, a small sample that consented and completed the study.However, given the study context the data was representative.

Conclusion
The study revealed that risky sexual behavior and acts of substance abuse among street and slum youth are high.Results showed risky sexual activity due to high consumption of alcohol and substances among the youth.Many of the slum and street children were staying alone with limited guidance from parents or guardians.Innovative social and evidence-based interventions (EBIs) are needed, especially addressing youth's vulnerability including staff training needs to meet the challenges.The safe space and drop in centre approach in the slums can attract more vulnerable slum youth.These must provide a comprehensive one stop centre /safe space based service for such youth.Obtaining data from youth upon entry is helpful in determining appropriate interventions but regular assessment and screening to follow up progress and determine outcomes is crucial.
Field experiences and discussions with study respondents revealed that self-esteem and positive coping is generally low among street and slum youths, severely affected by homelessness, survival sex and high alcohol usage which heighten high risk behaviors.Providing vocational skills training for employment with HIV interventions is very critical.Improving peer, parental and other neighborhood support may serve more as resilient enhancing activities.
Social disorganization of some slum communities' structures with limited or poor attachments to church, youth groups and mixtures of cultures and tolerance are among the drivers for high risk sex.We need to build young slum people skills to socially, cognitively and positively reframe their slum perception and mind set as well as provide comprehensive services that are a one stop centre for all services.Obtaining comprehensive data from youth upon entry about the home educational, sexuality, drug use, resources, suicide and adversities is helpful and must be framed in a manner that facilitates the development of culturally-tailored appropriate prevention interventions for youths.
Street and slum youth perception of sexual risks appears to be diminished because of the stressful circumstances they find themselves in coupled with high use of drugs.In spite of all these odds, these children have a high level of surviving alone in such difficult circumstances in a very turbulent society.There is need to make HIV testing more robust and readily available and also use social media tools including cellphones and face book to communicate HIV messages more regularly.

Table 1 :
Demographic characteristics of Kampala slum youth Seeking help at UYDEL Centres.

Table 2 :
Sexual behavior, and Substance use among Kampala slum youth.

Table 3 :
Substance use among Kampala slum youth Seeking help at UYDEL Centres.