solvent-abuse-pakistan

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solvent-abuse-pakistan

This publication is available from:

UNODC

Country Office for Pakistan

P.O.Box 1051

61-A, Jinnah Avenue

11th Floor, Saudi Pak Tower

Islamabad, Pakistan

United Nations System in Pakistan Publication

UN-PAK/UNODC/2004/1 - June 2004

THE UNITED NATIONS SYSTEM IN PAKISTAN


Copyright© 2004 United Nations Office on Drugs and Crime

All rights reserved

United Nations System in Pakistan Publication

No. UN-PAK/UNODC/2004/1

Designed by: UNODC Country Office for Pakistan

Disclaimer

“The opinions, figures and estimates set forth in this publication do not

necessarily reflect the views or carry the endorsement of the United

Nations”

ISBN 969-8567-07-0

THE UNITED NATIONS SYSTEM IN PAKISTAN

ISLAMABAD

2004


This research study would not have been possible without the

support and encouragement of Anti Narcotics Force (ANF),

Government of Pakistan. We would like to extend our

acknowledgment to all its collaborating partners, government

facilities, service providers, non-governmental organization etc. For

their support and help rendered during the entire phase of data

collection. We would also like to thank Dr. Kamran Niaz, Regional

Adviser, GAP, UNODC, Ankara, for his valuable comments and

guidance during the conceptualisation, planning phase and

reviewing of this study. Above all, our special gratitude is extended to

all the street children who facilitated and participated in the Study.

This study was conducted as part of UNODC funded project

“District Level Drug Abuse Prevention” AD/PAK/02/F51.

AIDS

ANF

CNS

DU

FGD's

GIT

GO's

HIV

IDU

KI's

NGO

RTI

SPSS

UN

UNICEF

UNODC

VSA

Yrs.

Acquired Immunity Deficiency Syndrome

Anti Narcotic Force

Central Nervous System

Drug use

Focus Group Discussions

Gastro Intestinal tract

Government Organizations

Human Immuno Virus

Injection drug use

Key Informants

Non Governmental Organization

Respiratory Tract Infections

Statistical Package for Social Sciences

United Nations

United Nations Children’s Fund

United Nations Office on Drugs & Crime

Volatile Substance Abuse

Years.


Executive summary

1. Background & Introduction

1.1 Street Children

1.2 Solvent Abuse

01

04

2. Research & Methodologies

2.1 Defining the problem

2.2 Aims & Objectives

2.3 Research Methodology & procedures

2.3.1 Case Definition

2.3.2 Subject Selection

2.3.3 The Questionnaire

2.3.4 Interview Procedures

2.3.4.1 Focus Group Discussion

2.3.4.2 Key Informant Interview

2.3.5 Ethical Standards

2.3.6 Data Management

3.Results

3.1 Demographic information

3.1.1 Gender & Age

3.1.2 Nationality & Migration Status

3.1.3 Religion

3.1.4 Family Information

3.1.5 Educational Qualification

3.1.6 Income, Source of Income & Spending

08

08

09

09

09

10

10

11

11

12

12

14

14

15

16

16

17

18


3.2 Living Conditions & group dynamics

3.3 Medical & Health Problems

3.4 Solvent Abuse

3.4.1 Substances Abused

3.4.2 Quantity used

3.4.3 Effects of solvent abuse

3.4.4 Reasons for use

3.4.5 Consequences of use

3.4.6 Treatment

3.5 Use of other drugs & HIV awareness

3.5.1 Use of other drugs

3.5.2 HIV Knowledge & Risk Practices

3.5.2.1 HIV Knowledge

3.5.2.2 HIV Risk Practices

3.6 Magnitude of problem

3.7 Key Informant interviews

3.7.1 Police Station

3.7.2 Drug abuse treatment facility

Recommendations

References

19

21

21

21

23

24

25

26

28

28

28

30

30

31

32

33

34

35

37

41

3.1

3.1.2a

3.1.4

3.1.5a

3.2.1a

3.3.1a

3.3.3a

3.3.6a

3.4.1a

3.4.1b

3.4.1b

3.4.2.2a

3.6.1

3.6.2

Sampling distribution

Major cities from where children flux into Lahore & Peshawar.

Parental marital status

Education Status

Sleeping place at night

Types of solvent abused and its daily cost in Pakistani rupees

Frequency of use of solvents

Treatment history

Various forms of tobacco used by street children

Use of other drugs during past 30 days

Prevalence of drug abuse in street children

Use of condoms during sexual intercourse

Study sites

Estimated prevalence


A total number of 416 children with

equal distribution from all four cities i.e.,

Karachi, Lahore, Peshawar and Quetta

participated in the study. Respondents were

predominantly males, with only 07 girls (1.7%)

included in the sample. The mean age of

children using solvents was 14.3 ± 2.52 years,

with the children in Peshawar slightly younger

(13.0 ± 2.33 yrs) than the children found in

other cities. The maximum proportions of

children were between 15 to 16 years of age.

The largest proportions of children interviewed

were Pakistani (81%), more than half of whom

had migrated from smaller cities. 12.5% of the

total children were Afghani followed by

Bengalis (5.8%). One third of the children

interviewed belonged to single parent families

with large family size. Almost three quarters of

the children were not currently living along

with their families. These children prefer

staying in groups, had no permanent place to

live, had been sleeping in parks (50%), friends

place(12%) and darbars (6.7%) etc. Seventy

Six percent (76%) of the children never

attended formal education. The remaining

24% had 3.01 ± 1.97 years of educational

attainment. The average daily income reported

was Rs. 79.7 ± 44.7, which was sourced

through cleaning cars, scavenging solid waste

garbage and begging.

Fifty five percent (55%) of the children

complained of at least one medical problem

that they were currently facing . The major

problem reported were Respiratory tract

infection; RTI's (30%), followed by Fever

(19.7%), GIT upsets (18.7%) and skin

infections (12.6%).

Adhesive glues was the primary drug of

choice consumed by 374 (90%) of the

interviewed street children. Other solvents

abused include petrol (25.5%) and thinners

(10.6%). Use of Petrol was significantly

popular in Quetta (43%) and Peshawar (41%).

In Karachi children were found to be involved

with glue (95.2%), Thinners (27.6%), Petrol

(13.3%), as well as Tincture(5.7%). An

average amount of Rs. 39.7 ± 30.1 is being

spent on these solvents with minimal

geographical variations. A little more than 60%

of the children reported regular use of these

substances for more than 2 years through

various techniques. On Average they inhale

almost 80 gm. Ninety Five percent (95%) of

the children stated that solvents are easily

available from the local market. More than

half of the times money is pooled in by various

children and thereafter procurement is used in

a group. Relief of tension, euphoria and

drowsiness are the major effects reported to


e felt on use of the solvent drugs. In contrary,

upon non-availability the feeling of anger,

agitation, restlessness, irritability, and

generalized aches were the major problems

reported. The major factors leading a child into

the use of solvents were friends and peer

pressure, reported by more than half of the

children interviewed. Only 20% of the children

had undergone any sort of treatment for drug

abuse problem. More than two third of the

children were unaware of any organization or

facility where they could be detoxified and

rehabilitated.

Information regarding use of other drugs

was also gathered. Hashish was found to be

the most prevalent among the group as 62.5%

children reported regular use during the past

30 days. Other drugs used during the past 30

days were Bhang (4%), Opium (3.6%) and

Synthetic drugs (5.3%). Only one child

conveyed use of heroin, while there was no

injection drug use reported. 53.8% of the

children had heard about HIV/AIDS. Among

these, 62.5% knew that it is spread through

sexual intercourse, while 19% knew that it can

be transmitted by syringes contaminated with

the virus. However, information regarding its

prevention was inadequate, as 44.6% stated

that sexual intercourse should be avoided

altogether to protect oneself from HIV. 28% of

the children thought that HIV can be avoided

by using various medicines. A high HIV risk

situation was noted, when sexual practices of

these children were evaluated. The average

age at the initiation of sexual activity was

reported to be 10.6 ± 2.2 years, with a high

number of sexual partners both males and

females was found. Only 20% informed of

using a condom, while the remaining 80% of

the children reported never using a condom.

One quarter of the children reported

exchanging sex for money.

Information gathered from the key

informant interviews, documented a very

unsatisfactory knowledge and awareness of

issues related to street children, and more

importantly the understanding of solvent

abuse among this extremely high-risk group.

An overall lack of clarity was observed

regarding detoxification of solvent abuse in the

existing drug treatment facilities was noted,

compounded by absolutely no rehabilitation

program for these children.

The report is structured in four major sections.

Section 01 presents background and introduction of street children, as well as basic

conceptual information on solvent abuse and the burden of the disease.

Section 02 gives the aims and objectives of the study as well as a description of the

research methodologies adopted. It provides information on subject selection, sampling

procedure, data collection procedure and data analysis

Section 03 reports the results of the study and is further distributed into 6 major

subdivisions. Sub-Section 1 provides information on the socio-demographic

characteristics of the children. Sub-Section 2 describes the group dynamics and current

living arrangements of these children. Sub-Section 3 is related to information on drugs

other than Solvents, HIV/AIDS knowledge and risk behaviours. Sub-Section 4 provides

description regarding prevalence and related information on solvent abuse. The last subsection

of this part provides information on the various drug treatment facilities, exists in

the country.

Section 04 provides recommendations and proposes various strategies to address the

issues.


&

BACKGROUND

Introduction Section one

BACKGROUND

& Introduction


BACKGROUND & INTRODUCTION

Section one

Street children are defined as

“children who have to work on

the streets because their families

need money to survive, children

from poor families who sleep on

the streets, orphan and

abandoned children whose

parents have died because of

illness or war or for whom it was

simply impossible to look after

their children”.

1.1 Street Children

st

With the advent of the 21 century human

population is going through the cycles of feast

and famine. This can be observed especially

in under developed countries and in

developing nations like Pakistan. This

population explosion not only gives rise to a lot

of physical /environmental stresses such as

shortage of food supply, fuel and energy,

different type of pollutions etc but also the

psychological ones. They can be anxiety,

tension, worries, depressions several other

psychopathologies due to deprivation of need

fulfilment and coping with technological

advancement. Such frustrations would be

damaging for the inter personal relationships

and the consequences have to be borne by

both the individual and society disrupting the

over all growth pattern. The consequences

can be traced from the elementary unit of the

society which is family such as disrupted and

dysfunctional abuse of authority and power

and gradually to the over all social structure.

This can be an increasing rate of crime and

violence. Such a malfunctioning society

always strikes hard against the powerless

including women and children.

Children in particular are highly susceptible

to these highly volatile situations. They face

denial of their basic rights. The inequalities

they face due to adults behavior are

unimaginable, however the manifestations are

the same in any setting. The circumstances

faced are the same all over the world.

Parents, friends and the physical environment,

all play an active role in the development of a

child's personality. Any neglect, deprivation,

indifferent parental behavior possibly due to a

disrupted relationship can cause serious and

irreversible damage to the developing

personality, pushing the child into deviant

behavior. Many societies witnessed an influx

of children ending up on the streets due to

indifferent attitudes of their parents, family

break-up or poverty. Alarmingly, the numbers

have been constantly growing into significant

epidemiological proportions. Societies have

failed significantly in doing enough to follow

through and to create secure environments for

these displaced children known as “Street

Children”.

1

Street children are defined as “children

who have to work on the streets because their

families need money to survive, children from

poor families who sleep on the streets, orphan

1


Section one

and abandoned children whose parents have

died because of illness or war or for whom it

was simply impossible to look after their

children”. They live, breath in the air

poisonous for their survival but they find

relieve in it. Their social or economical state

compels them to involve in anti-social activities

and they suffer critically due to drug and

sexual abuse or similar other harmful factors.

These children are deprived of the essential

relationship with vital societal institutions that

traditionally provide sources of support and

ensure an individual's well being and

happiness in society. They are at alarmingly

high risk for a myriad of physical and

psychological problems as a result of both the

circumstances that preceded their

homelessness, and as a direct consequence

2.

of life on the streets

The United Nations estimates around 100-

3

140 million street children world wide. Out of

these only 20 million children live on the street

around the clock without their families. In

South America at least 40 million, in Asia 25

million, in Africa 10 million and in Eastern and

Western Europe approximately 25 million

children and youth live on the street 4,5

. It is

estimated that approximately 90 percent of

street children in Central America sniff glue.

Considering the situation in South Asia it is

revealed that almost every country of this

region suffers the same dilemma. In India, 18

million children have been reported to live or

work on the streets of urban India, labouring

as porters at bus or railway terminals; as

mechanics in informal auto-repair shops; as

vendors of food, tea, or handmade articles; as

street tailors; or as rag pickers, picking

through garbage and selling usable materials

7

to local buyers . In Bangladesh, Nepal, Sri

Lanka the issue is critically reported, due to

illiteracy and deprivation of basic needs the

8

countries face the identical problem .

Pakistan, which has a population of 140

million, is no different from other South Asian

countries as its urban settings portray the

same bleak picture. The situation is worse in

its biggest Metropolis city, Karachi that is

home to more than 10,000 street living

9

children. The course of researches revealed

many disturbing facts about these children.

They brave extreme weather conditions and

live in an extremely battered environment,

exposed to any eventuality that comes their

way. They usually form groups to protect

themselves from exploitation and abuse,

which is common in street culture. Their gang

leaders are usually older boys who abuse

them in return for ensuring their safety . The

gang leader who arranges for their meals and

for their favourite distractions, (these children

have been found addicted to a number of

toxicants, including substances and

chemicals) keeps whatever these children

earn.

These children are facing not only the

scarcity of resources but are living

under noisy, dirty, unsafe and

impersonal environment

which leads to frustration

because their goals

related to Subjective

Well Being( SWB)

are thwarted or

blocked. Street

children are those

who are least able to

protect themselves. In

almost every aspect of their

lives; they are subject to

unconscionable violence, most often

perpetrated by the very individuals charged

with their safety and well being. This

frustration leads to the feelings of hostility

towards its source. But single handily they

cannot achieve what they desire thus attach

with similar others on the principle of

reciprocity of liking. As being a part of group

not only social but also emotional needs can

be meet. Thus they become a staunch

member and do whatever others do. This

could be an explanation for their association

with gang-crime which in turn build their

courage to be involved in criminal activities

and solvent/drug abuse.

2

3


Section one

1.2 Solvent Abuse

Defining Solvent Abuse has proven to be a

far more arduous task than it has been for

most other drugs. In broader terms solvent

abuse or more accurately called Volatile

Substance Abuse (VSA) has been defined as

the “deliberate inhalation of gases, chemical

fumes or vapours for mind-altering and

recreational purposes in order to get a “high”

similar to the intoxication produced by

alcohol”. Solvents are chemicals that change

from liquid form into gases or vapours at

ordinary room temperatures. Their abuse

potential is directly related to their ability to

produce intoxication and repeated abuse may

result in psychological dependence or other

harmful health effects. The prevalence and

public health effects of volatile substance

abuse are often underestimated and local

knowledge of the phenomenon is inadequate.

The wide range of organic solvents available

in many common products further complicates

the situation. Compounds such as diethyl

ether, chloroform and nitrous oxide have been

deliberately inhaled for recreational purposes

since the early 1800s. Solvents from

adhesives such as glues, (notably toluene),

typewriter correcting fluids and thinners (1,1,1-

trichloroethane), hydrocarbons such as those

found in cigarette lighter refills [forms of

liquefied petroleum gas (LPG), largely butane],

aerosol propellants, halocarbon fire

extinguishers and gases such as nitrous oxide

are among the compounds or products which

may be abused in this way. Petrol and its byproducts

(gasoline) as well as Acetone

(propanone) have also been reported to be

abused, especially in developing communities.

While the inhalation of volatile substances

for mind-altering and recreational purposes is

a long-standing problem in the developed

world, the phenomenon appears to be of a

recent origin in most countries in Asia and the

Pacific region. Research has shown that VSA

is primarily an adolescent phenomenon, with

the highest levels of prevalence reported

among 15 and 16 year olds. VSA gives rise to

dose-related effects similar to those of other

hypno sedatives. Small doses can rapidly lead

to euphoria and other disturbances of

behaviour similar to those caused by ethanol

(alcohol), and may also induce delusions and

hallucinations

. 19,20,21,22,23,24.

Inhalants can be breathed in through the

nose or the mouth in a variety of ways, such

as:





“Sniffing” or “snorting” fumes from

containers;

“Bagging”sniffing or inhaling fumes

from substances sprayed or

deposited inside a plastic or paper

bag;

“Huffing” from an inhalant-soaked rag

stuffed in the mouth;

Spraying aerosols directly into the

nose or mouth.

Inhaled chemicals are rapidly absorbed

through the lungs into the bloodstream and

quickly distributed to the brain and other

organs. Research has shown that the

chemical substances found in inhalants

produce acute effects similar to subanaesthetic

concentrations of general

anaesthetics, as well as to the effects of

classical CNS depressant drugs, such as

alcohol and the barbiturates. This is

characterized by a rapid high that resembles

alcohol intoxication with initial excitation

followed by drowsiness, dis-inhibition, lightheadedness

and agitation. Nearly all abused

inhalants (other than nitrites) produce a

pleasurable effect by depressing the CNS.

There is evidence that toluene, a solvent

found in many commonly abused inhalants

including glue, paint and nail polish removers,

activates the brain's dopamine system. The

dopamine system has been known to play a

role in the rewarding effects of many drugs of

abuse. Nitrites, in contrast, dilate and relax

blood vessels rather than acting as

anaesthetic

agents. For

the

anaesthetics,

evidence

suggests

that

enhancement

of

GABAenergic

inhibition may

be an

important

cellular target for

their acute effects, just as it is for alcohol and

25,26

other depressant drugs.

Within minutes of inhalation, the user

experiences intoxication along with other

effects similar to those produced by alcohol.

Alcohol-like effects may include slurred

speech, an inability to coordinate movements,

euphoria, and dizziness. In addition, users

may experience light-headedness,

hallucinations, and delusions, e.g., a feeling

that they can fly. Because intoxication lasts

4

5


6

only a few minutes to a maximum of about 45

minutes, abusers frequently seek to prolong

the high by continuing to inhale repeatedly

over the course of several hours. Once the

initial 'buzz' wears off, users experience

symptoms similar to a hangover and often feel

tired and drowsy. It is suggested that rather

than using the term 'addiction' for solvent

abuse, 'dependence' is a more useful concept

as this allows for two dimensions: both the

physical and psychological effects. However,

tolerance can develop with regular use of

volatile substances so that increased

inhalation is needed to get the same effect.

The psychological effects of volatile substance

abuse vary from person to person. However,

there is always a general sense of euphoria

and of omnipotence associated with the

process. Chronic users may also experience

difficulty with socialization and communication,

which can result in a pattern of antisocial

,27,28

behaviour.

Accidental death or injury can happen

especially if users are in an unsafe

environment such as near a busy road.

Becoming unconscious also carries with it the

risk of death through choking. In fact any

method of use which hinders breathing (such

as sniffing with a plastic bag over the head)

increases the likelihood of death from

29,30,31,32,33

asphyxiation.

RESEARCH methodologies

Section two

&

&

RESEARCH

methodologies

7


RESEARCH & METHODOLOGIES

Section two

2.1 Defining the Problem

2.3 Research Methodology & Procedures:

The National Assessment Study on the

Drug Abuse Situation in Pakistan, 2000,

documented that there are approximately

500,000 chronic heroin users (including drug

injectors) in the country. The study also

highlighted an emerging problem of solvent

abuse among young people; street children in

particular. Research has documented Street

children to be one of the most vulnerable

populations for various deviated behaviours

such as substance abuse. Data from the

study did not allow comment on the issue in

any detail, but Solvent abuse was most

commonly reported from urban areas in the

major cities like Lahore Karachi, Rawalpindi

and Peshawar.

However, the extent to which this

marginalized and vulnerable group is abusing

solvents deserves further attention, as does

the wider question of what can be done to

alleviate the drug and other social problems

amongst this particularly needy group of

young people.

The following study is therefore designed in

order to get a better understanding on solvent

abuse among adolescents in Pakistan, and

utilize the results in the formulation of

interventions for the street children with the

solvent abuse problem.

2.2 Aims & Objectives:

The objectives of the study:

To determine the …

i) prevalence of solvent abuse among

street children in Pakistan;

ii) patterns and trends of solvent abuse

among street children in Pakistan;

iii) level of awareness about adverse

consequences of solvent and drug

abuse;

iv) the demographic and socio-economic

profile of solvent abusers, living

circumstances including group dynamics;

v) health and social consequences of

solvent abuse;

vi) sources of financing solvent and drug

abuse;

vii) knowledge of HIV / AIDS and associated

risk practices; and

ix) the nature, extent and quality of

treatment and rehabilitation facilities, if

any, for street children abusing solvents.

2.3.1 Case Definition

Reaching a case definition was a highly

tedious task, primarily due to the scarcity of

research undertaken on the subject in

Pakistan, as well as the highly complicated

dynamics of this vulnerable population. The

task required defining 'street children' initially,

followed by delineating 'solvent abuse' and

finally merging the two to reach a case

definition to be used for the purposes of our

study. Street children were defined as:

“children for whom the family support base

has become increasingly weakened and who

must share in the responsibility of family

survival by working on city streets and market

places. Nevertheless, while the street

becomes their daily time activity, the majority

return home most nights.”. Based on the

preceding, the eligibility criteria for subjects to

be included in the study was described as:





Street children spending a minimum of 10

hours on the street, irrespective of

residential status

Either male or female

Aged between 9 to 19 years

using any of the products included in the

list of abusive solvents (annex 1) continuously

for a minimum of past 6 month, not less

than 3 times a week.

Based on the above mentioned criteria, our

case definition was:

“All street children, either male/female, aged

9 to 19 yrs, willing to participate in the study

and had been regularly using solvents in the

past 6 month for not less than 3 times a week.”

2.3.2 Subject selection

The study was conducted in the four

provincial capitals of Pakistan i.e., Karachi,

Lahore, Peshawar and Quetta. Extensive

efforts were made to achieve a representative

sample of the study population. Thus, prior to

the selection of study subjects, a

comprehensive mapping of street children

was done in the respective city, utilizing

multiple resources. Thereafter, multiple sites

with highest concentration of street children

were selected in each city, from where equal

proportions of study subjects were recruited.

Subjects found eligible were otherwise

excluded from the study but unwilling to

participate.

8

9


Section two

2.3.3 The Questionnaire

A team of researchers including an

epidemiologist, psychologist, social scientists

and social workers working with street children

developed the questionnaire. A 03 days

training on data collection was conducted in

Karachi, which included issues on subject

selection, explaining the rationale and

objectives of the study to the subjects,

acquiring informed consent and a thorough

understanding regarding each question. The

training was followed by pre-testing of data

collection technique and questionnaire

implementation on 42 subjects (10% of overall

sample) at 3 different sites.

The questionnaire was pre-tested on a

sample of 10% of the actual sample size,

which was modified, and all required changes

were incorporated. Information on various

demographic and socio-economic variables,

information related to the family of the child

and current living arrangements, knowledge of

the drug abuse problem and awareness of the

consequences was collected. Information

related to average daily income, sources of

income and mode of spending were also

noted. Information on drug use practices i.e.,

severity and routes of administration etc.,

Medical, social and psychological

consequences of solvent abuse were

obtained from the child. Knowledge related to

HIV, its modes of transmission and prevention

as well as an evaluation of high-risk HIV

behaviour and practices was done at the end.

2.3.4 Interview procedures

Four data collection teams, each

comprising of a field supervisor and three

interviewers worked simultaneously in their

targeted areas. All interviewers were social

science graduates, having a minimum of 2-3

years fieldwork experience. As already

mentioned a three-day training of interviewers

was held in Karachi. The work schedule of all

interviewers was prepared by the field

supervisor in such a way that each interviewer

was assigned to conduct three interviews per

day at various targeted sites. An equal

number of children were selected on the basis

of incidental sample for data collection from

the identified sites. Furthermore, to capture

the entire segments of the street children

population, each site was visited on different

days of the week as well as on different times

of the day. Among children present at a

selected site, one child was selected by the

interviewer, after the drug abuse status was

determined. This was followed by an informed

consent and a structured interview, which took

an average time of 35 minutes, was

conducted.

2.3.4.1Focus Group Discussions

In addition to collecting questionnaire

information, purposive sampling on the basis

of stratified grouping was

applied to hold seven

Focus Group

Discussions (FGD's).

Each group consisted of

Typical & Critical cases,

and at least one child

from each age bracket

i.e., upto 10 yrs, 11 to 14

yrs and more than14 yrs.

A total number of 8 ± 1 member

participated in each group discussion, which

were conducted in Karachi (Jehangir Park),

Quetta (Baldia Park, Railway station),

Peshawar (General Bus stand, city station

sara-e-pul) and Lahore (Abbot road, Ravi

park). A total number of 58 children

participated in this activity altogether. The

purpose of FGD's was to indicate and

illustrate:

I.

II.

III.

IV.

antecedents of nurturance on

behaviors and attitudes;

reason of incomplete education;

living conditions and group dynamics;

effects, reasons and consequences

of solvent abuse;

2.3.4.2 Key Informant Interviews

To acquire information about the existing

services for the treatment and rehabilitation of

street children, as well to comprehend the

awareness of the service providers, 18 key

informant

interviews

were

conducted

with

individuals in

a regular

contact with

these

children

frequently.

Two major

groups of

people were

interviewed

i.e., people

Box.4 Key Informants interviews

Karachi





Lahore

Police station – Metha dar

Police station – Darakhshan

Azam Clinic - Pakistan Society

Marie Adelaide Drug rehabilitation

Programee

Police station – Qilla Gujar Singh

Police station – Naulakha

Nighaban centre

Nai Zindagi

Model drug abuse treatment centre –

Mayo Hospital

Peshawar





Quetta






Police station - Hashtnagar

Police station – Kabuly Bazar

Dost Welfare Foundation

Lady Reading Hospital

Police station - Pushtoonabad

Police station – City

Milo Shaheed Trust

Psychiatric Ward – Civil Hospital

Edhi centre

10

11


Section three

involved in providing drug detoxification and

rehabilitation facilities, as well as police

officials. Various government and non

governmental organizations were selected to

identify and recognize the existing resources

available for drug detoxification and treatment

of these children. Moreover, an evaluation of

the knowledge and awareness as well as the

skills of these providers is a requisite for

developing interventions in future.

On the other hand, police and law

enforcement agencies are known to come into

interaction with these children frequently.

Moreover, these institutions play a key role in

providing first hand information regarding the

criminal involvement and illicit activities done

by these children. It was equally important to

know that if children are involved in such an

activity, how frequent is such an involvement

while at the same time, what sort of

rehabilitation and rectification methods are in

place.

2.3.5 Ethical Standards

(i)

(ii)

(iii)

(iv)

informed consent of the interviewee;

ensuring privacy and confidentiality of

personal information;

non-inclusion of subject's personal

information in data files;

Presentation of results in aggregate;

form, without individual identification.

2.3.6 Data Management

A data base was specifically designed in

Fox Pro for the purposes of data entry. The

completed questionnaires after field editing

and checking by the field supervisors were

received at the data management unit. All

questionnaires were assigned a code number,

and the forms were edited by the data

manager. After editing, data set were double

entered in the software designed for data

entry, followed by data cleaning and analysis.

STUDY results

12

To assure adherence to the ethical

standards of epidemiological research,

procedures followed included:

STUDY results

13


Solvent Abuse Among Street Children in Pakistan

STUDY RESULTS

Solvent Abuse Among Street Children in Pakistan

Section three

Four hundred and twenty three (423) interviews were conducted in the 4 target cities. 29

eligible children refused to participate in the study (primarily girls 19), with an overall non

response of 6.5%. The overall distribution of sample is given in Table 3.1

yrs) and 21.2% (more than 17yrs) respectively. The city wide age distribution is given in Fig

3.1.1a.

The demographic and socio-economic

profile of the street children who participated in

the study is presented in this section.

Table 3.1 Sampling Distribution

Karachi Lahore Quetta Peshawar OVERALL

n (%) n (%) n (%) n (%) N (%)

Interviews conducted 110 110 110 110 440

Non response 02 (1.8) 07 (6.3) 09 (8.1) 11 (10) 29 (6.5)

Incomplete forms 05 (4.5) 01(


Section three

from where these children have largely migrated

are shown in Table

3.1.2

Table 3.1.2a. Major cities from where

children influx into Lahore & Peshawar

LAHORE

3.1.3 Religion

96.4 % of the children interviewed were

Muslims. Of the remaining 3%, 12 were

Christians and 1 child was reported to be a

Hindu. Two children did not know about their

religion. The figures reported are in accordance

with national data.

3.1.4 Family Information

PESHAWAR

City n City n

Faisalabad 10 Mardan 8

Gujranwala 10 Swat 7

Sheikhupura 3 Charsada 5

Karachi 3 Rawalpindi 4

Sialkot 3 Kohat 4

Seventy two percent (72%) of the

respondents (300) were not currently living with

their families. Of all the homeless children, 9.3%

(28) did not know about their families. Out of the

remaining, only 2% were in daily contact with the

family. Almost one third were meeting the

family at least once a month while a

substantial percentage 43.6% had contact

almost once every six months. 2.3% had lost

complete contact with their families. The

graphical presentation of the responses is

given in Fig 3.1.4a.

43.6

Fig. 3.1. 4a

Fre qu en cy of Fa mily C on tac t

daily

once or tw ice a w eek

once or tw ice a month

more than a monthbut less than 6 months

no contact

2.3

2.2 7.6

Further information regarding

parents, and immediate family members was

obtained. A high proportion of children were

reported to belong to large families. The mean

family size (immediate members) was

reported to be 8.89 ± 2.45, with more than

38% of the children belonging to families

having 10 or more immediate members.

Analysis of the birth order of the children

interviewed revealed that 53.6% were middle

born, 15.2% were elders while the remaining

22

30.4% were the youngest.

Further information regarding the parents

depicted that almost half of the children

reported that their parents were living together.

Approximately one third of the children

belonged to single parent families. Thus either

one of the parents was deceased or otherwise

there was a marital disruption in the form of

divorce or separation. Further details are

provided in Table 3.1.4a.

Table 3.1.4a

Parental Marital status

Marital status n (%)

Currently living together 205 (49.3)

Single parent 132 (31.7)

Both parents died 50 (12.0)

No information 29 (6.9)

FGD's indicated that children complained

about their parent's attitudes as indifferent

towards them. A few statements as per

verbatim are quoted to give a clear perception

of their relations with parents;

“my parents abused each other and in the

end verbally and physically abused me as

well”. According to another child “my father

always demanded good grades in school but

never gave money for stationary and books. If

I was not doing good in my school, I was

forced to work for living”. One of the child

informed, “My father abuse drugs and under its

influence used to beat us”.

Information generated from the FGD's

showed that the upbringing of most of these

children was done in the parenting fashion

”,

called “rejecting-neglecting parenting style

Most of the children further complained of

larger family size and scarcity of resources.

They were of the opinion that their family

expenditures were more than their monthly

earning, and their parents were always

pushing them to contribute to the family

income and share some of the financial

responsibilities. Children also reported their

family as a disrupted unit, in which the parents

were always quarreling with each other and

releasing their aggression and anxieties on

children, infact cursing their existence.

3.1.5 Educational Qualification

Results of the analysis regarding

educational attainment has shown that overall

76% (316) of the total children interviewed

never went to school. The situation was found

to be the worst in Quetta, where 90% of the

children never attended school. The mean

16

17


years of education completed by those who

went to school was 3.01 ± 1.97. See table

3.1.5a for details.

Section three

Karachi Lahore Quetta Peshawar OVERALL

n (%) N (%) n (%) n (%) N (%)

Never went to

school 78 (74.3) 75 (68.8) 91 (90) 72 (72) 316 (76)

Cannot read or

writ e 82 (78) 83 (76.1) 91 (90) 67 (67) 316 (76)

Mean years of

education

completed 2.8 ± 1.7 3.1 ± 1.7 5.0 ± 3.4 2.2 ± 1.2 3.0 ± 1.9

Lack of interest (35%) followed by nonavailability

of finances (23%), detestation for

teacher (22%), required to work (10.5%) and a

non-interest of parents in the child's education

(6%) were the main reasons reported for the

discontinuation of education.

As already mentioned in the previous

section, children regarded their families as

broken and dysfunctional. Children reported

under group discussions that the apathetic

attitude of parents made them irritated and

frustrated. This was further amplified by the

teacher's attitude. They said: “Teachers beat

us for being undisciplined, can't learn lessons

properly or can't even study properly”. It can

be added over here that children who are

distilled and rejected are more likely to drop

out from school, to develop emotional

problems and to become juvenile delinquents.

They are usually unhappy and are lonely,

suffer from a higher incidence of both physical

and mental disorder experiencing problems

that range from poor health and adjustment to

a higher rate of criminal activity to suicide

conversely. It is well supported by various

researches that such destitute children face

38,39

problems mentioned above.

3.1.6 Income, Sources of income &

Spending

140

120

100

80

60

40

20

0

125

Cleaning

cars

69

Fig. 3. 1.4a

57

Begging

50

27

Waiters

So urc es o f Inc ome

The primary source of income for the

majority of children was cleaning / washing

cars (30%), followed by scavenging garbage

(16.7%) and begging (13.8%). Other sources

of income included physical labor, selling of

flowers, toys, balloons, combs etc., on the

22

13 13 13 12 15

Pick

pocketing

Skilled

Labor

Misc

street. A minor proportion of children (3%)

reported involvement in minor crimes such as

pick pocketing etc., Two of the children

interviewed also reported of involvement in the

peddling of drugs such as Hashish.

A negligible fraction (3%) sourced their

income from skilled

work i.e.

mechani

cs,

con

structi

on work

etc. The

various sources of

income for the street children are given in Fig

3.1.6a. The average daily income reported

was Rs. 79.7 ± 44.7 earned after working for

an average of 8.63 ± 5.74 hours per day.

Using the provided estimates, an

approximation of the average monthly income

was found to be Rs. 2395. The mean daily

income was significantly low for children

interviewed in Peshawar (45.14 ± 16.18) while

the remaining cities reported a mean daily

income, which was almost double. Only

30%(126) children informed that they share

their income with their families.

3.2 Living Conditions &

Group Dynamics

As already mentioned, 72% (300) of the

respondents were not currently living with their

families, and, 9.3% (28) out of these had

completely lost contact with their families. The

current living conditions and circumstances

were further explored.

Children were inquired about the place

where they had been sleeping during the past

30 days. Almost half of these children had

been sleeping in the streets or parks in the last

30 days. 12% reported staying the nights with

their friends. Upon further exploration, this

night stay was either at home or at the place

where this friend works. Approximately 7% of

the children reported sleeping at Darbars and

shrines as well. The responses are given in

Table 3.2.1a.

Table 3.2.1a Sleeping place at night

With the family

Street/ Parks

Friends

Darbar / Shrines

Work Place

Others

116 (28%)

206 (49.5%)

50 (12%)

28 (6.7%)

04 (1.0%)

06 (1.4%)

18

19


Section three

Results show that a large number of

children interviewed had no permanent place

to live/sleep and had been drifting around

various places. It was interesting to note that

all such children never spend nights alone, but

had been sleeping in the company of other

street children, and stay in groups. The groups

are usually of a large size (60% of the children

have reported sleeping at places where more

than 10 children are present). Only 8% of the

children have been sleeping in a group of less

than 5 children. A group leader, who is usually

an elder, either the strongest boy or the one

who owns the place, almost always controls

the group.

Children under focus groups shared their

feeling of dismay by pointing towards the

ambience around them as disconsolate.

According to them jungle rules prevail, as the

one who is mighty or superior (in any form)

surmounted others. Children were of the

opinion that living in open places gives rise to

the feeling of insecurity and they remain

vulnerable to abuse, which extends from

verbal to physical and even sexual. The main

fears reported by the younger children were of

sexual assault from the elder boys, while the

elder children themselves were concerned

about physical dangers. The majority of

younger children informed that they were at an

absolute loss to enjoy a sound sleep, as they

are in constant state of anxiety from all the

exposed dangers, which is not only from

nature but more from their own kind. The

formation of groups and the need to stay

together could be explained in the light of this

as well as the fact that being human beings,

and for need fulfilment, they had to live

together and became a part of group. Being a

part of group they perform all the rituals and

meet institutionalised norms of the group; the

finding is well supported by several

researches conducted on personality

,

development . This is an extremely important

point, which needs consideration and can be

utilized when preventive packages are

formulated for these children.

3.3 Medical & Health

problems

Evaluation of the medical status had shown

that 55% of the children complained of at least

one medical problem that they were facing

currently. The major problems reported were

Respiratory Tract Infection (30%), followed by

Fever (19.7%), GIT upsets (18.7%) and Skin

Infections (12.6%). Other complaints included

Headaches, Generalized Myalgias,

Weakness, Eye Infections etc.

Among those who complained of prevailing

illness, 47% had sought medical treatment. Of

the remaining 53%, the lead reason reported

for not seeing a doctor was lack of finances

(39%). Other important reasons reported were

a fear of injection (20%), don't know a doctor

(9.8%), don't want to go because doctors are

not cooperative with them (9.9%) and self

treatment (3.3%). The health seeking

behaviour needs to be considered when any

primary health care interventions are designed

for this group.

3.4 Solvent Abuse

3.4.1 Substance abused

The use of various solvents by the

respondents is in conformity with what is seen

12-14,17

internationally. Adhesive glues is the

primary drug of choice consumed by 90%

(374) of the interviewed street children. This

feature has been found to be uniformly

distributed across all the four cities from where

data were collected. A high proportion of

samples reported use of other solvents as

well, including petrol (25.5%) and thinners

(10.6%). Slight differences were noticed in the

use of these secondary solvents across cities.

The use of Petrol along with adhesive glues

was significantly popular in Quetta (43%) and

Peshawar (41%), while the practice was

almost negligible in Lahore, where only 7

children reported the adjunct use of petrol

along with adhesive glues. As a matter of fact,

a significant proportion of children found in

Peshawar were involved in the use of petrol

alone (26%), without getting involved with the

use of adhesive glues. Karachi has reported a

more complicated picture, where children have

been found to be involved with multiple

20

21


Section three

substances. Thus while glue is the main drug

used (95.2%) children have also been using

Thinners (27.6%), Petrol (13.3%) and a minor

proportion (5.7%) has reported use of Tincture

as well.

Table 3.3.1a

Solvents abused

Adhesive Glues

Petrol & related

products

Thinners

Miscellaneous

Average Daily cost

(mean ± sd)

Types of Solvents abused

and its daily cost in Pak Rs.

Karachi Lahore Quetta Peshawar OVERALL

n (%) N (%) n (%) n (%) n (%)

100

(95.2)

14 (13.3)

29 (27.6)

07 (6.7)

47.5 ±

36.5

107

(98.2)

07 (6.4)

02 (1.8)

01 (0.9)

41.6 ±

26.3

94 (92.2)

44 (43.1)

10 (9.8)

05 (4.9)

38.7 ±

26.2

73 (73)

41 (41)

03 (3)

01 (1)

30 ± 28

374

(89.9)

106

(25.5)

44 (10.6)

14 (3.3)

39.7 ±

30.1

Results have shown that an average

amount of Rs. 39.7 ± 30.1 is being spent on

these solvents, which forms almost 50% of

their average earning. (see section 3.1.6).

Slight geographical differentiations were

noticed; children in Peshawar reported to have

spent an average daily amount of Rs.30 on

buying these substances in contrast to Rs.47

spent by a child living in Karachi. The numbers

are however in parallel to their average

income.

Further analysis revealed that the

maximum proportions (62%) of children

interviewed had been using these substances

for periods greater than 2 years. A minor

Box 3.3---- Techniques used for i nhaling

Adhesive Glues

It should be noted that it is the vapor

given off by the product that is used and

the product its elf, e.g. glue, is not

ingested into the body. Abusers have

reported 3 different techniques through

which they inhale the product :

The most practiced technique is the use

of a solvent from a soaked cloth reported

by 80% (329) of the respondents.

Typically some of the mat erial (20 gms)

is poured into the cloth, which is then

rolled in the sh ape of glove. Thi s in local

terms is known as ‘Dum’. The ‘dum’ is

then sniffed, or kept in the mouth and

the fumes are inhaled.

The second favourite technique is the

inhalation of drug in a plastic bag

[17%(71)]. The plasti c bag containi ng the

glue is then held over the face and nose

and the fumes are inhaled.

Inhaling the fumes by putting the solvent

in a bott le was also descr ibed by 35

(8.4%) of the respondents. Again the

substance is po ured into a bott le, and

the bottle is then brought closed to the

nose and the fumes are inhaled. In some

instances a plast ic pipe (straw) is place d

above the level of the solvent, the other

end is placed in the mouth and the whole

substance is breathed in.

Finally, 6.5% (27) of the respondents

reported using the solvent directly from

the can (tube in rare instances) The

majority of cases have reported making a

small hole in the can, and then after

holding it close to the nose or face and

inhaling the fumes until the whole

substance is breathed in.

proportion initiated drug use in the past year

(18.2%) and a similar number (19.7%) had

been using it for more than 1 year but not

more than 2 years. This is suggestive of the

fact that the practice is not a very new

phenomenon, but most of the children

interviewed were chronic users. However,

since a strict case selection criteria was also

used, all experimental and sporadic drug

users were screened and excluded from the

study. 95% of the children stated that they do

not face any difficulty in procuring the

solvents, and it is easily available from the

local market at standard rates. As described

by the respondents it is just as simple as going

to a shop and asking for an inhalant. More

than half of the times (54%) the activity is

reported to be a group based activity, in which

the money is pooled in by all members of the

group and one of the member then buys the

substance for the entire group. Box 3.3.

describes the various techniques used for

inhaling adhesive glues. The illustrations of

the mechanism are given in Figures 3.3.3

A & b.

3.4.2 Quantity used

Analysis has shown that on an average 80

gms of adhesive glues is being used each

day during the past one month. Further

analysis revealed that the maximum proportion

of children (45.2%) have reported using 280

gms of glue followed by 750 gms (24.8%),

40 gms (19.2%) and

80 gms (10.8%)

respectively.

Children

were

inquired

about

the

frequenc

y of use,

the

answers to

which are

provided in

table 3.3.3a.

approximately 20% of

the

children informed that they have been using

the solvents only once daily. Almost one fourth

of the children reported using these drugs 2 to

five times daily, while another 32% reported

use upto 10 times a day. A substantial portion

of the children (15%) reported that using

solvents round the clock. These children use

the solvent through a cloth, which always stays

with them in their hands, or pocket, and they

are continuously busy in inhaling the fumes of

the solvent, which is poured into this cloth.

22

23


3.4.3 Effects of Solvent abuse

Research has shown that the chemical

substances found in the inhalants produce

acute effects similar to sub-anaesthetic

concentrations of general anaesthetics, as

well as to the effects of classical CNS

depressant drugs, such as alcohol and

barbiturates. Children were inquired of the

feeling experienced after solvents are inhaled;

the responses are given in Fig 3.3.3a.

140

120

100

80

60

40

20

0

117

Relief of

tension

Fig. 3.3.3a

111

Euphoria

65

Drowsiness

Feelings experienced on using Solvents

36 33 31

Confident &

Strong

Cannot

express

Light

headedness

19 16 16

A typical episode of solvent abuse as

described by children themselves is a mixed

Table 3. 3.3a. Frequency of use of solvents

Frequency of use n (%)

Once daily

02 to upto 05 times daily

06 to upto 10 times daily

All the time

Agression

Section three

Nostalgia

80 (19.2)

97 (23.3)

136(32.7)

103(14.7)

Others

feeling of euphoria and contentment and a

relaxed mood followed by a sound peaceful

sleep. Children describe the feelings as

ones that make

them forget their

worries and

tensions, and feel

happy about

whatsoever

situation they are

into. A few

children told the

interviewers that

they are unable

to define the

feelings, but

generally it is a nice feeling. A large number

of children reported that use of solvents

made them feel strong and powerful enough

to overcome all the worries and problems in

their lives. A minor proportion also described

the feelings as nostalgic which reminded

them of their home and the good times of

their lives.

One of the biggest hazards of

compulsive drug use is that it fosters drug

dependence and addiction. Users continue

to take drugs despite adverse social and

medical consequences, and behave as if the

effects of the drugs are needed for continued

well-being. Although research suggests that

the physiological dependence is rare with

solvents, the magnitude of the need to

repeated usage can vary from a mild desire to

a craving or compulsion to use the drug. The

respondents were inquired about the feelings

they undergo if the solvents are not taken. The

responses are shown in Fig 3.3.3b.

160

140

120

100

80

60

40

20

0

142

Anger &

Agitation

Fig. 3.3.3b

69

Restlessness &

Irritability

Symp toms r epo rted upo n un availib ility o f solv ents

3.4.4 Reasons for Use

54

Generalized

Aches

38

Inability to work

33 30

Abdominal

cramps & GIT

upsets

The respondents were inquired about the

various factors associated with the aetiology of

solvent abuse. The major factor to lead into

the use of solvents reported by more than half

of the children (53.4%) was friends and peers.

Among other factors reported, neglect, group

violence, a way to forget about the past and

curiosity were significant as shown in fig 3.3.4.

The issue was further explored in groups'

discussions, which focused on not only the

Headache

22

Depression

14 15

Semiconsciousness

Others

reasons which led to the initiation of solvent

use, but also discussing factors leading to the

continuation of these agents. The role-played

by peers and group membership not only

emerged strongly as the factor initiating the

use of solvents but also acted as the leading

reason to the continuation of the habit. A large

number of children reported that they started

drugs as to meet the social norms, which gave

them immediate gratification in response. The

importance of group membership was

highlighted for survival among street children

in the previous section (see section 3.2).

However, while the peer pressure and social

circumstances played a strong role in initiating

drug use, the effects of the solvents

themselves helped continuous solvent abuse.

The feeling of euphoria and happiness that

was immediately experienced made the

children forget all worries and helped relieve

the tension, which these children face. The

CNS depressing effects of the drugs made the

children enjoy sound sleep for longer duration.

Thus it can be deduced that, solvent or

drug abuse work as an anaesthesia,

decreases physical and emotional pain, induce

sleep, decrease appetite (one of the factors

leading to malnutrition), increases energy

levels and adds excitement. It also provides

24

25


Section three

Fig. 3.3.4a

Etiology of Solvent Abuse

Curiosity Forget the past Relatives

Enviornment Neglection Domestic Voilence

Group Violence Peer/Friends Misc

53.6

Them with a sense of belonging to the ingroup

and gives them courage to commit

crimes and higher levels of violence.

3.4.5 Consequences of Use

4.3

A range of negative consequences and

problems can arise from persistent use of

solvents. When explored in FGD, the children

revealed various medical and social problems

they have been facing over the past two years.

Although youth is generally a time of relatively

good health, but, the nature of continuous

exposure to the streets and the associated

lifestyles makes street children vulnerable to a

range of health and other problems which are

4.3

8.4

8.7

5

2.6

3.1

9.9

not typically experienced by other young

people. The majority of children did not

report any severe medical problems that

they faced, however minor ailments and

health problems have been reported.

Although use of solvents has its own

untoward effects on the health of the

Box 3.

Medical Consequences of Solvent Abuse

Chest Infections & Breathing

(16.4%)

Fever (16%)

Generalized Weakness & Myalgia

(8.9%)

Skin Infections (3.6%)

Gastric upsets (3.8%)

Headache (2.6%)

Urinary Infections (1.9%)

Semi-consciousness (1.0%)

Misc (5.5%)

individual, but the results of surveys of

chronic solvent abusers are reassuring that

physical organ damage is not a significant or

widespread problem for most abusers. The

degree and duration of abuse required

producing harm to heart, brain, kidneys and

liver is unknown because several years of

35,43,17

regular abuse appears to be necessary.

157 children (37.7%) reported that they

had been facing problems due to solvent

abuse. The number one social problem quoted

was neglect, hatred and non-acceptance by

the society (46.5%). Incidences have been

reported where children were cast out from

their families (4%) and lost jobs (2.3%) due to

their involvement with solvents. In depth

Box 3.

Social Consequences of

Abuse

Neglect ion & Hatred (46.5%)

Group Violence (21.7%)

Police threats (12.9%)

Out casted from family (4.1%)

Living in non hygienic

condition (3.5%)

Lost jobs (2.3%)

Others (9.9%)

FGD's revealed that children viewed their

parents as impassive who else would take

care of them. People considered them

rebellions, runaways and apathetic towards

others. They are generally thought to have no

values (moral, social, religious or ethical) and

are largely gangsters involved in crime that

extended from simple theft to drug paddling or

even commercial sex. Children reported that

such negative attitude of the society inculcated

a feeling of hatred, neglect and denial of care.

They pointed out that everyone around hated,

manipulated and exploited them so they would

also do the same to them. Such kind of

negativity when expressed and exposed took

the shape of violence, which according to the

children is a reciprocation of what they have

received.

Amazingly, the children were positive that

to repay society they needed strength not only

from outside but from their own selves, which

could only be achieved through abuse of

solvents or other drugs. This façade terrified

others around them so at least for the time

being helped in their survival without many

efforts and courage and so the vicious cycle

continues. Thus it is difficult to comment

whether spending time on the street made

them so or the abuse of solvents/drugs gave

rise to such consequences. The effect could

be reciprocal. The principle of trial and error

was the first step towards a long journey

without a destination.

26

27


Section three

3.4.6 Treatment

When asked if they ever tried to break the

habit of solvent use, and how it could be done,

only 20.7% of the respondents reported to

have undergone any sort of treatment, and

that too was a self-treatment in more than half

of the incidences. Approximately 70% of the

children were unaware of any organization /

institution where they could be treated and

rehabilitated.

The results are summarized in table

3.3.6a.

Table 3.3.6a

Treatment History

Question n (%)

3.5 Use of other Drugs

& HIV awareness

3.5.1 Use of other Drugs

The relationship between the use of

Solvents and other drugs is a complex one.

Although a possibility can be linked, but

research is unable to answer whether the

use of solvents leads to abuse of more

potent addictive drugs, such as heroin etc,

44

in future.

A lifetime prevalence of tobacco use was

seen among these children, in all provinces.

The various forms of tobacco use were

2

categorized as Cigarettes, Pan & Gutka.

Cigarette smoking is an extremely prevalent

(87%) characteristic found in all the four

cities, while eating Pan (filled with tobacco)

120

100

80

60

40

20

0

87

39

17

Cigarette Pan Gutka

95 96

20

2

76

74

8 4

0

82

60

56

OVERALL Lahore Quetta Peshawar Karachi

is a common practice in Peshawar among

street children abusing solvents. As seen in

our research, Karachi presented a

complicated picture, where all forms of

tobacco were being used. It was seen that

these children become involved with tobacco,

start smoking at a very young age (the mean

age ± sd of the children at starting smoking

was found to be 9.89 ± 8.6). Cigarette

smoking appears to be the first addictive agent

that has been used by the majority of these

children, before they start experimenting and

getting involved with other drugs as well as

solvents.

Information about other drugs including

hashish, opium, marihuana and heroin use

was also gathered. The respondents were

initially asked about the use as “ever used”

which in case of a positive reply was followed

by regular use of the drug during the last 30

days. Information on alcohol intake was also

gathered.

Use of hashish was found to be significantly

prevalent among this group. While 68.8%

children reported that they had “ever used”

hashish, an overall 62.5% children reported

regular use during the past 30 days. The

citywide distribution was fairly uniform, with

the highest prevalence noticed in Quetta

(80.4%) followed by Lahore (73.4%), Karachi

(65.7%) and surprisingly Peshawar (55%).

Although only 8.9% of the total reported

regular use of alcohol, yet by contrast, street

children from Quetta rated as the highest

users of alcohol (21.4%).

Table 3.4.1 b Use of other drugs during past 30

days

Alcohol

Hashish

Opium

Bhang

Heroin

Synthetic drugs

8.9%

62.5%

3.6%

4.1%

0.2%

5.3%

A minor proportion of children reported

involvement in other drugs during the past 30

days i.e., Bhang (4%), Opium (3.6%) and

Synthetic drugs (5.3%). Only one child

reported regular use of heroin. It is worth

noting here that the overall research

conducted in the country has shown a similar

27

picture in which Hashish is the most common

drug of abuse among drug users, with varying

proportions of drug abusers reporting use of

other drugs. The drug use situation of street

children is not different, from the overall drug

abuse picture in the country. However

additional research is required to develop a

sound understanding of the subject, as well as

to study the aetiology of substance abuse.

Citywide distribution of drugs ever used by the

2. Local form of tobacco which is kept in mouth and chewed.

28

29


Section three

study subjects is presented in Fig 3.4.1b

Table 3.4.1b Prevalence of drug use in street children

80

60

40

20

0

OVERALL Lahore Quetta Peshawar Karachi

Hashish Alcohol Bhang Opium Heroin Synthetic drugs

3.5.2 HIV Knowledge & Risk Practices

Drug use among street children is closely

related to other health issues and risk-taking

behaviour such as prostitution, sexual

exploitation and unsafe sex practices, all of

which have contributed to a growing incidence

of AIDS/HIV among this particular group. In

this study we have tried to evaluate the

existing knowledge of the children regarding

important aspects of HIV / AIDS as well as two

of the risk practices i.e., Injection drug use and

sexual practices.

3.5.2.1 HIV Knowledge

children had heard about HIV/AIDS. Among

those who had heard of the disease, three

major sources of information were revealed

Box 3.4.2a HIV related Knowledge

Ways of HIV Transmission

Sexual Intercourse (62.5%)

Germs (10.6%)

Syringes (18.7%)

Blood exchange (2.9%)

Razors (2.9%)

Misc (5.8% )

Don’t now (6.7%)

Methods to pro tect HIV transmiss ion

Avoid sexual intercourse (44.6%)

Medicines (27.7%)

Use new syringes (8.9%)

Medicines (4 .1%)

Condoms (4%)

Avoid drug use (2%)

Don’t know (6%)

.43.9% had heard of the disease from the

television, followed by the local NGO's

working against HIV/AIDS and its paramedic

staff (32.7%). While the remaining had

received their information via inter-personal

communication i.e., friends and other

acquaintances.

infection is spread and the methods to protect

themselves from getting infected. 62.5% of the

children who had heard about HIV/AIDS knew

that it is spread through sexual intercourse,

but 44.6% stated that sexual intercourse

should be avoided altogether to protect

oneself from HIV. The detail of all responses is

given in the Box.3.4.2a.

3.5.2.2 HIV Risk practices

Two major HIV risk practices were explored

including Injection drug use and Sexual

practices. As already seen in the previous

section, although drug use has been found to

be a fairly common characteristic, none of the

children interviewed reported that they had

ever injected drugs.

In contrast several risky sexual practices

were highlighted, which puts these children at,

a high risk for contracting HIV. high

proportions (53.4%) of the children were found

Question

Table 3.4.2.2a

Sexual Practices of street children

mean ± sd

Average age at initiation to sexual activit y* 10.6 ± 2.2

To be sexually active, with the highest level of

sexual activity reported by children interviewed

in Lahore (73.4%) in contrast to 37% in

Peshawar. The average age at the initiation of

sexual activity was reported to be 10.6 ± 2.2

years. A high number of sexual partners both

males and females were found. The mean

number of sexual partners both males &

females are given in Table 3.5.2a. While a high

number of sexual partners are seen, the use of

condom was almost negligible. 80% of the

children reported they had never ever used a

condom. Only 7% informed of always using a

condom, while the remaining 13% had been

using condoms occasionally. The graphical

presentation is given in Fig 3.4.2.2a.

There has been evidence in which these

children were found to be involved in

commercial sex work, as 105 (25.5%) of the

416 children interviewed informed that they

had exchanged sex for money.

13.7

Never Sometimes Always

7.2

Street children were asked about whether

they knew about HIV/AIDS. 53.8% of the

The subject was further explored by

asking children whether they knew how the

Current Number of sexual partners

Females

Males

2.6 ± 2.5

5.1 ± 6.1

79.1

30

31


Section three

3.6 Magnitude of the

problem

In Pakistan, reliable data on the prevalence

of solvent abuse and related problems is

extremely scarce. The issue is further

complicated by the highly sensitive nature of

the problem, difficulties in accessing this

population, complicated group dynamics and

ignorance of local authorities regarding the

subjects.

The methodology adopted for providing

estimates of solvent abuse prevalence was

based on direct and indirect estimation. Direct

estimation was done by counting the exact

number of street children in a specified

location and determining proportions actually

involved in solvent abuse. Prior to conducting

this exercise, a mapping exercise was

undertaken and a complete mapping of street

children was done in all four cities. Thereafter,

six sites where maximum mobilization of street

children was recorded were subsequently

selected for prevalence estimation in each city.

Furthermore, to capture the entire segments of

the street children population, each site was

visited on different days of the week as well as

on different times of the day. The detail on the

locations from where data were collected is

given in Table 3.6.1.

Table 3.6.1

Karachi

1. Abdullah Shah Ghazi

2. Hussainabad

3. Jamshair Road

4. Korangi

5. Tariq Road

6. Saddar

Lahore

1. Data Darbar

2. Circular Road

3. Larri Adda

4. Railway Station

5. Macleod Road

6. Multan Road

Study sites from where prevalence estimates are generated

Peshawar

1. Firdous Cinema

2. Haji Camp

3. Jhangi Mohalla

4. Kabuly Bazaar

5. Railway Station

6. Khyber Road

Quetta

1. Habib Nala

2. Jinnah Road

3. Lower Karez

4. Pushtoon abad

5.Saryab Road

6.

Indirect estimation was done by

information gathered from Key informants.

Regional police and public health personnel

reported the estimated numbers of children

involved with solvent abuse. NGO

representatives, Government hospital staff,

and people working with welfare

organizations reported same figures.

Ironically, the exact number of street

children is unknown, as no formative

research among street children had been

conducted in the country to provide these

estimates. Anecdotal information, however,

is available with organizations working for

the street children. According to the

information gathered from these

organizations, the approximate number of

34

street children in various cities is as follows:

1. Karachi 12,000

2. Lahore 8,000

3. Peshawar 4,500

4. Quetta 2,500

Based on these estimates the number of

children involved with solvents abuse were

calculated by multiplying the probability

estimate with the total number of street

children in each city. The details are provided

in Table 3.6.2:

Table 3.6.2

Estimated Prevalence of

Solvent abuse among street children


OVERALL

Karachi

Lahore

Peshawar

Quetta

Estimated

Prevalence

39.6 %

45.3%

36.9%

36.8%

41.7%

Direct Estimates

95% CI

33.1 – 46.1%

32.0 – 58.6%

24.0 – 49.8%

23.9 – 49.7%

28.5 – 54.9%

Indirect

Estimates

(range)

-

50 - 60%

30-35%

25-30%

40-50%

Total

Number

-

5,500

2,900

1,700

1,100

Care should be taken before extracting

nation wide estimates from the prevalence

reported from this study. The number

represents a pictorial suggestion from the

major cities, and takes account of chronic

users only, and is based on self-reported data.

Therefore the estimates can be biased

downward due to a combination of under

reporting and under coverage. Moreover,

generalization of these results to smaller cities

and females is not suggested due to nonresponse

and non-participation by a significant

proportion of females.

3.7 Key Informant Interviews

As mentioned previously, 18 key informant

interviews were conducted with individuals in a

regular contact with these children frequently,

to gather information about the existing

services available for street children, as well

as to comprehend the awareness of the

service providers. The details on these

interviews are given in box 4. Information

generated from the key informant interviews

documented very unsatisfactory knowledge

and awareness of issues related to street

children, and more importantly the

understanding of solvent abuse among this

extremely high-risk group. Moreover, the

perceptions and knowledge of the interviewed

people related to treatment, and rehabilitation

32

33


Section three

of these children was far below the optimal

level.

3.7.1 Police stations

Street children come into conflict with the

law in many ways. Some children may be

coerced into involvement in illegal activities,

from bag snatching and petty theft to drug

peddling. On the other end of the spectrum,

these children are often stigmatised by police

and the public, who believe they are doing

something wrong even if they are playing,

reinforcing the perception of street children as

criminals. Children are not always taken into

justice systems when in conflict with the law,

but may be dealt with “informally” when they

are perceived to have behaved wrongly.

Children worldwide are subject to harassment

by police including beatings, abuse and other

violence, including sexual violation (ref- Asia

Pacific report).

Inquiry into the criminal history showed

that 49.3% of the children has been arrested

at least once in their lifetime by the police.

According to the children this arrest was a part

of the routine police raids, which is observed

once or twice every year. Further exploration

into the reasons for which children were

arrested revealed that the maximum number

of arrests were done on account of minor

thefts (40%), followed by solvent use(26%),

violence and street fights (10%) and drug

peddling (5%). Interestingly 12.7% did not

know the reason why they were arrested.

Based on the above reasons, we

ensured to visit various police officials and

gather information on street children from

their perspective. The key points are

summarized as such:

All police officials contacted

documented the presence of street children

abusing solvents in their respective area.

The numbers reported were in accordance

with the prevalence estimates provided by

the direct estimation method used. The

estimates provided by police officials are

also given in Table 3.6.2 under indirect

estimation.

Police officials were asked about

their perception on why street children use

solvents. According to most, easy availability

was the sole reason, which has led to an

increas use of solvents among children.

100% of the officers interviewed

raised concern over involvement of these

children (30 - 50%) in minor criminal

activities such as pick pocketing, minor theft,

and shop lifting. This feature was in

agreement with the information obtained by

the children themselves, where it was seen

that the police had arrested almost half of the

children at least once in lifetime.

Another growing concern was the

mounting proportions of these children getting

involved in prostitution, and drug trafficking,

which was informed by officials in Lahore and

Karachi. The number of children involved in

such activities was feared to be reaching up to

20%, with numbers consistently increasing.

Half of the police officials reported to

have taken such children into police custody

occasionally, but due to the absence of any

available facilities, no remedial action could be

taken. Thus these children are kept under

custody for a few days, and are later set free.

Only one official in Peshawar

reported that children involved with substance

abuse have been referred to a drug

detoxification centre for treatment.

3.7.2 Drug abuse treatment facilities

Among drug abuse treatment facilities

visited, 4 (40%) were government facilities

while the remaining were non-governmental

organizations (NGO's). Based on the

information collected, the key issues are

summarized as under:

By and large, the core staff consulted

was not found to be very familiar with all

phases of preventive services (i.e., primary

prevention, treatment and rehabilitation) for

this sub group of drug using population. Thus,

while the majority of staff members met were

comfortable with the issues of treatment and

rehabilitation of other drugs e.g., heroin, an

obvious deficiency was noted in the translation

of this concept to children/adolescents

treatment and solvent abuse. The issue of

solvent abuse is still alien to the drug

treatment service providers, and henceforth

there either are no services available, or those

that do exist do not provide it in an appropriate

manner.

All of the facilities visited were found

to have tailored their services for treatment of

heroin addicts, which is the leading cause of

admission in these facilities. The government

facilities visited in Peshawar (Lady Reading

hospital) and Quetta (Civil hospital) informed

that they had admitted children involved with

solvents recently, but the proportions were

negligible (< 5%) as compared to patients

admitted for treatment of other drugs. Twelve

chronic solvent abusers were undergoing

detoxification in Azam clinic (Pakistan society)

Karachi, but the management authorities

reported a lack of clarity regarding their

34

35


Section four

36

treatment methodology and a rehabilitation

program for these children was non existent.

Furthermore, none of the facilities

mentioned had any staff members specifically

trained in Paediatric practice, child or

adolescent health, as well to deal with

treatment issues of solvent abuse. More than

half of the key informants interviewed (60%)

expressed lack of knowledge and non existent

resources to combat this form of substance

abuse.

However, an interest was shown to

work for provision of services for this segment

of population. Upon inquiry regarding what

sort of support is required by the facilities to

work against the issue of solvent abuse in

street children, all facilities focused on

provision of training of their staff members on

the problem of street children and solvent

abuse.

None of the facilities visited informed

of any primary prevention activities taken up

for these children.

Reviewing the existing services for the

treatment of solvent abuse in the country, the

situation is extremely dissatisfying. The core

fact, which is of significant importance, is that

the majority of health services have been

developed for adults. Many such services

rarely recognize the unique issues of young

people, particularly those of street children,

and rarely try to accommodate for their age

specific behaviours. Therefore, many young

people view health services as unfriendly,

threatening, mystifying, unhelpful and

inappropriate. Thus even when facilities do

exist, specialist drug services tend to poorly

understand issues pertinent to young

people. Young people tend to be treated as

mini-adults, and their particular needs get

ignored.

RECOMMENDATIONS

RECOMMENDATIONS

37


RECOMMENDATIONS

Section four

Recommendations

Based on results of this study, it is suggested

that Modified Social Stress Model (MSSM) be

applied to have an ABC analysis (Antecedent,

Behaviour, Consequences) of solvent abuse

among street children. A dichotomous strategy

should be designed to achieve such an

analysis, which aims to minimize (if not

eradicate) and to prevent the probability of

occurrence with a short and long term

perspective.

There is an urgent need for the

development of a comprehensive national

strategy, for the control and prevention of

solvent abuse. The strategy should

concentrate on bringing together government

entities (both national and provincial),

international agencies (UNODC, UNICEF,

UNAIDS et al) key stakeholders, community

based organizations (CBO's), nongovernmental

organizations (NGOs),

empowering the target community itself to

enable holistic programming and excellence in

prevention, care and support. The overall

national strategy developed should

encompass the following:


Owing to the lack of awareness of the

issue among the general public and drug

abuse service providers, an extensive

population based awareness campaign is

suggested, which aims on raising the

general public awareness about this

emerging problem in terms of national

development, stability and integrity. Various

communication channels including mass

media, print media and local communication

channels need to be mobilized for an

effective impact of the activities.

Components of the campaign

should address the street children as well,

providing them information on drug abuse

especially Solvents, the untoward

consequences, motivation for treatment, and

awareness regarding HIV risk behaviours

and safe practices.

Secondary prevention activities

should take the form of providing drug

treatment & rehabilitation services to the

children involved with solvents or other

drugs. While designing such programmes,

the issue of solvent abuse need to be

addressed in a broader perspective as

opposed to merely a mental health problem.

Special importance should be given to the

dynamics of this population that is very

different from other high-risk populations. The

differences between solvent abuse and other

forms of addiction should be kept in mind,

when treatment plans are devised. Thus if

existing drug treatment facilities need to be

utilized, up-gradation of the material resources

and training of the staff on issues of solvent

abuse and especially the needs of street

children needs be considered. Training

modules should be designed and on going

training packages for capacity building should

be provided to GO's, NGO's, CBO's and

people dealing or in contact with these

children.

Special emphasis should be laid on

the rehabilitation of these children. The

rehabilitation programme should have

components on education, social skills, skill

development in the form of vocational

trainings, and placement of these children in

their families

In addition to the formal treatment

and rehabilitation activities, various outlets (in

the shape of shelter homes or drop in centres)

need to be established in areas that are

accessible to street children, possible regular

contact with the service providers and

motivational sessions could be conducted.

These shelter homes or DIC's would

encompass :

The task of educating street children

in basic interpersonal and social skills.

Empowering children with civic

sense

Enhancing their capability to

communicate and comprehend messages

effectively like simple arithmetic and

vocabulary.

Training in self defence to avoid

risky behaviour and practices

Knowledge about rights and duties

Moreover, these centres can act as

sources of information dissemination and

contact points for these children. The centres

need to be linked to the chain of drug

treament and rehabilitation services and

proper referral can be made when and where

required.

Outreach services need to be

provided in the form of mobile units linked with

a network of health and legal facilities. In an

ideal scenario, the outreach services need to

be connected with the DIC's and shelter

homes for maximum effectiveness.

38

39


REFRENCES

Section four

Formative ongoing research to

thoroughly understand population dynamics,

behaviour and practices as well as underlying

beliefs which lead to the behaviours, aetiology

of solvent abuse etc., are issues which need

be studied further. There is a need to involve

women in these research studies, and

ascertain baseline situation in smaller cities.

An important avenue for epidemiological

and behavioural research is the risk

assessment of this population for HIV

prevention and control.

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