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Int J Adolesc Med Health 2008;20(3):367-374

Characterizing health behaviors and infectious disease

prevalence among Filipino street children
Levi Njord, BS 1,2 Ray Μ Merrill, PhD, MPH1, Rebecca Njord, BA 2 Jeanette DR
Pachano, BSN, RN2 and Austin Hackett, BS 2

'Department of Health Science, College of Health and Human Performance, Brigham Young
University, Provo, Utah;2 TURN International, Provo, Utah, United States of America

Abstract: Purpose: To describe health problems and social, environmental, and health behavior
characteristics among street children in Manila, Philippines. Methods: A cross-sectional survey and
clinical tests that included chest radiographs blood, urine, and stool samples were completed with 179
street children, ages 8-17 years, served by Childhope-Asia Philippines. Results: The most frequently
occurring health problem was coughing, followed by fever, dyspnea, diarrhea, and then blood in the
stools. Males compared with females were more likely to be kicked, punched, or slapped by an adult.
Among males, 65% are current smokers and 52% have consumed alcohol. Among females, 37% are
current smokers and 67% have consumed alcohol. The percentage of children with low hemoglobin
was 91% for males and 16% for females. The percentage of children with low hematocrit was 69%
for males and 22% for females. Of all children tested, 7.9% had hepatitis B, 12.3% had pneumonia,
and 25.5% had ascariasis. Conclusions: Filipino street children have a high level of infectious disease,
with females experiencing higher levels of coughing, dyspnea, and fever whereas males had higher
levels of diarrhea. Males are more likely to be physically abused and to smoke tobacco whereas
females are more likely to drink alcohol. Both males and females experienced depression and anxiety
and many children were sexually active. Diseases common among the population are pneumonia,
anemia, hepatitis Β and ascariasis, primarily due to their lack of adequate nutrition, close living
proximity, and unsanitary living conditions.

Keywords: Street children, health behaviors, infectious disease prevalence, Philippines

Correspondence: Ray Μ Merrill, Department of Health Science, Brigham Young University, Provo, Utah
84602 United States. Tel: 801-422-9788 (work); Fax: 801-422-0273 (fax); E-mail: Ray_Merrill@byu.edu

Submitted: February 06, 2008. Revised: June 01, 2008. Accepted: June 08, 2008.

INTRODUCTION pressures o f street life by taking illicit sub-

Poverty is a leading factor associated with
illness among all populations but especially
among street children (1). The conditions
commonly experienced by transient street
children that increase health risks include
extreme environmental conditions, infectious
diseases, sexual predators, inadequate food,
and the social stigma (2-4). Many street
children learn to cope with the social
stances and participating in gang behavior
(5-6). Street children often cope with the
financial pressures o f street life through
involvement in prostitution, begging, parking
cars, or collecting trash (7).
Currently researchers classify street
children as children on the street and
children o f the street (8-9). Children on the
street refer to those w h o seek employment

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368 FILIPINO STREET CHILDREN
on the street but live at home and have
regular contact with their families. Seventy-
five percent of Filipino street children fall
into this category. Children of the street are
those who work and live on the street and
maintain little or no contact with their
families. This group represents the other
25% of street children in the Philippines
(10). The transient nature of street children
coupled with frequent shifting between
characterization groups make precise esti-
mates of their numbers in selected areas
difficult. In general, the estimated number
of children on and of the street in Manila is
between 50,000 and 75,000, according to
the Department of Social Work and
Development in the Philippines (11).
Although the reasons for becoming a
street child in the Philippines are diverse,
coming from a family or community of low
socioeconomic status is a common charac-
teristic (9). Low socioeconomic status tends
to be associated with a general lack of
fundamental resources needed to support a
healthy lifestyle. Families of low socio-
economic status may also view their children
as potential sources of income, resulting in
the children being forced into the labor
market at an early age (12). Physical, sexual,
and emotional abuses from family or neigh-
bors are common among these children,
leading many to retreat to the streets (13).
Some street children are enticed to this
lifestyle by other street children, viewing
street life as a social avenue that is free of
responsibility (14).
Street children have been studied at
length with respect to social problems, yet
little descriptive epidemiologic information
is available on the general health profiles of
street children throughout the world. The
purpose of this study is to describe health
problems and social, environmental, and
health behavior charac-teristics of street
children in Manila, Philippines.
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METHODS
Study participants were enrolled from a
sample of street children under the auspices
of Childhope Asia-Philippines, a non-profit
organization that provides social services
for street children in the greater Manila
area. Inclusion criteria for the study were
that the child be 8-17 years of age, have
lived on the street with no contact with
family for at least 6 months, and be
affiliated with Childhope Asia-Philippines.
One-hundred and seventy-nine participants
qualified for the study. Each participant was
assisted by a social worker, nurse, or
physician in completing the questionnaire
and the clinical laboratory evaluation. Data
collection lasted two weeks. A cross-
sectional study design was used to profile
the prevalence of health problems and social,
environmental, and health behavioral charac-
teristics. A series of clinical laboratory tests,
anthropometric measurements, standard vital
signs, and two chest x-rays were also taken;
all participants who completed the survey
also participated in the clinical evaluations.
Questionnaire
Questions were modeled after those found in
the KPC 2000, rapid catch survey (Macro
International/CSTS+ project, Calverton, MD,
USA, 20705), the block dietary data systems
survey (Nutritionquest, Berkeley, CA, USA,
94704), and the Zung depression scale (15).
Slight modifications in question wording and
structure were made to tailor questions to the
specific conditions of street children in
Manila. The questionnaire consisted of 50
items and, on average, took 15 minutes to
complete. Fourteen staff members of Child-
hope Asia-Philippines were trained on how
to administer the questionnaire.
Measures
The general health of the study participants
was evaluated through a series of clinical
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 LEVI NJORD, RM MERRILL ET AL
laboratory tests, anthropometric measure-
ments, standard vital signs and 2 chest x-
rays. The clinical laboratory test series
included a c o m p l e t e blood count (CBC),
blood protein profile and stool analysis. The
t w o radiographs were used to evaluate
pneumonia and tuberculosis infections.
Because of the high prevalence of tuber-
culosis in the Philippines, radiographs were
used instead of the purified protein
derivative ( P P D ) skin tests. The Brigham
Young University Institutional Review Board
approved this study on 28 March 2007.
Statistical analysis
Cross-tabulations were used for bivariate
analyses between selected variables; statistical
significance was based on the chi-square test
for independence (16). Differences in means
between independent groups were evaluated
using the t test and, when adjusted for other
variables, the F test (17). Relative risks
estimated were adjusted for age and gender.
Analyses were performed using S A S version
9.0 (SAS Institute Inc., Cary, N C , USA).
Statistical significance was at the 0.05 level.
RESULTS
Ages ranged from 8 to 17 ( M = 12.8, S D =
2.4). There were 107 males ( 6 0 % ) and 72
females (40%). M e a n age was similar
between males and females (P = .9017).
There was a significant difference between
males and females in place of residence.
For males the percentage in each location
was Calookan 18%, Lagro 19%, Mayon
21%, Tandang Sora 14%, Luneta 8%, Santa
Cruz 13%, and Binundo 8%. Corresponding
percentages for females were 21%, 6%, 7%,
6%, 17%, 25%, and 18% (P = .0004). Of all
children, 3 2 % were currently in school,
with no statistical d i f f e r e n c e between males
and females (P = .9695).
Selected health p r o b l e m s and social,
environmental, and health behavioral char-
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369
acteristics of street children in Manila are
presented in table 1. In order of most
frequently occurring to least frequently
occurring, health problems w e r e coughing,
fever, dyspnea, diarrhea, and blood in stools.
Coughing, dyspnea, a n d fever occurred
more often in females than males. A small
percentage of children experienced malaria
and convulsions. N o statistical differences
were found between the genders in pulse,
respiration, or body temperature.
The majority of children reported having
previously been kicked, punched, or slapped
by an adult or by a peer. Males were signifi-
cantly more likely than females to be kicked,
punched, or slapped by an adult. Above 2 0 %
of the children felt anxious or depressed on a
daily basis, with no significant difference
between genders. The majority of children
washed their hands and used soap the
previous day and also showered or bathed at
least two times in the previous week, with
the levels of these behaviors being signifi-
cantly higher for females than males. The
majority of children indicated eating at least
breakfast, lunch, or dinner on a daily basis.
Males were significantly more likely than
females to have earned money at a j o b in the
previous month. Thirty-six percent of males
and 3 8 % of females that reported being
sexually active also reported being involved
in prostitution or receiving money for sex.
N o statistical difference was found between
genders. A m o n g males, 6 5 % are current
smokers and 5 2 % have consumed alcohol.
A m o n g females, 3 7 % are current smokers
and 6 7 % have consumed alcohol.
Hematology, hepatitis, and blood chem-
istry a m o n g street children is presented in
table 2. Males experienced significantly lower
hemoglobin and hematocrit. The percentage
of children with low h e m o g l o b i n was 9 1 %
for males and 16% for females (P < .0001).
The percentage of children with low
hematocrit was 6 9 % for males and 2 2 % for
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370 FILIPINO STREET CHILDREN

Table 1. Assessment of selected physical, social, environmental, and health behavioral

characteristics according to sex among street children in Manila

Characteristics Males Females Chi-square or f

No. % No. % Ρ value
Physical
Diarrhea in past 2 weeks 47 44 28 39 0.5526
Blood in stool in past 2 weeks 18 17 10 14 0.6232
Cough in past 2 weeks 76 71 60 84 0.0381
Dyspnea in past 2 weeks 47 44 43 61 0.0297
Fever in past 2 weeks 58 54 50 70 0.0301
Malaria in past 2 weeks 5 5 2 3 0.5327
Convulsions in past 2 weeks 4 4 5 7 0.3246
BMI Μ = 15.6 SD = 2.7 Μ = 15.8 SD = 3.2 0.7962
Systolic blood pressure Μ = 102.4 SD = 13.4 Μ = 99.9 SD = 11.5 0.1999
Diastolic blood pressure Μ = 69.9 SD = 10.1 Μ = 65.7 SD = 8.2 0.0037
Pulse (one minute) Μ = 72.9 SD = 13.8 Μ = 71.5 SD = 12.1 0.2535
Respiration (one minute) Μ = 25.0 SD = 5.8 Μ = 24.6 SD = 5.2 0.6635
Temperature (Celsius) Μ = 36.6 SD = 0.5 Μ = 36.5 SD = 0.5 0.7427
Social
Kicked, punched, slapped by an adult
Never 16 15 20 28 0.0164
Sometimes (1 time per week) 50 48 39 55
Frequently (2-4 times per week) 27 26 7 10
All the time (daily) 12 11 5 7
Kicked, punched, slapped by a peer
Never 24 23 22 31 0.2381
Sometimes (1 time per week) 42 40 32 46
Frequently (2-4 times per week) 22 21 9 13
All the time (daily) 17 16 7 10
Feel anxious or depressed
Daily 22 23 13 20 0.8777
Weekly 37 39 25 39
Monthly 10 10 5 8
Never 27 28 21 33
Health Behavior
How often washed hands yesterday
Not at all 15 14 3 4 0.0431
Once 23 22 11 15
Twice 25 24 15 21
Three or more times 43 41 42 59
How often used soap yesterday
Not at all 22 21 6 8 0.0144
Once 29 28 14 20
Twice 16 16 10 14
Three or more times 36 35 41 58
How often showered/bathed last week
Not at all 7 7 0 0 0.0277
Once 23 22 10 14
Twice 18 17 9 13
Three or more times 57 54 52 73
Eats breakfast daily 50 47 43 61 0.0803
Eats lunch daily 59 56 44 62 0.4041
Eats dinner daily 64 60 46 65 0.5531
Ever been sexually active 14 13 9 13 0.9660
Ever received money for sex 5 36 3 38 0.9332
Currently smoke 68 65 26 37 0.0003
Ever consumed alcohol 52 52 42 67 0.0650

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 LEVI NJORD, RM MERRILL ET AL 371

Table 2. Hematology, hepatitis, and blood chemistry according to gender among street
children in Manila

Males Females
Mean Standard Deviation Mean Standard Deviation t Ρ value
Hematology
Hemoglobin 135.8 10.7 131.5 8.3 0.0028
Hematocrit 0.40 0.03 0.38 0.02 0.0005
Hepatitis
HBsAg 0.51 0.61 0.50 0.60 0.8585
Anti HAV Igm 0.31 0.04 0.31 0.04 0.6604
Blood Chemistry
Total protein 7.0 0.4 7.1 0.5 0.2243
Albumin 4.1 0.4 4.1 0.4 0.3909
Globulin 3.0 0.3 2.9 0.4 0.8478
Albumin/Globulin ratio 1.4 0.3 1.4 0.2 0.5287

Table 3. Nutritional intake among street children in Manila

Nutrients Mean SD
How many days over the last seven days did you drink or eat each of the following?
Plain water 6.2 1.8
Fruit juice 2.7 2.7
Other beverage 4.4 2.6
Any foods made with grains 6.0 1.9
Pumpkin, squash, carrots or potatoes 2.2 2.3
Other food made from roots or tubers 2.3 2.4
Green leafy vegetables 3.0 2.6
Mango, papaya 3.6 2.6
Other fruits or vegetables 3.1 2.5
Meat, poultry, fish, shellfish, or eggs 4.1 2.5
Any food made from legumes (beans) 2.4 2.3

Table 4. Risk of situations and behaviors according to current smoking status (yes vs. no)
among street children in Manila

Situations and Behaviors Relative Risk* 95% Clt

Kicked, punched, slapped by an adult (2+times per week vs. < 1) 3.1' 1.6,6.0
Kicked, punched, slapped by a peer (2+ times per week vs. < 1) IT 1.0,2.8
Anxious or depressed (daily/weekly vs. monthly/never) 1.0 0.8,1.3
Washed hands yesterday 3 or more times (vs. less) 0.8 0.6,1.2
Used soap yesterday 3 or more times (vs. less) 0.8 0.5,1.2
Showered/bathed last week 3 or more times (vs. less) 0.7· 0.6, 0.9
Eats breakfast daily (vs. less) 0.9 0.7,1.3
Eats lunch daily (vs. less) 0.9 0.7,1.2
Eats dinner daily (vs. less) 0.75' 0.6,0.9
Ever been sexually active (yes vs. no) 5.0' 1.2,20.9
Ever consumed alcohol (yes vs. no) 5.9' 2.8,12.5
* Adjusted for age and sex. ' P < .05

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372 FILIPINO STREET CHILDREN
females (Ρ < .0001). None had low total
protein, 7% had low albumin, 4% had low
globulin, and 58% had low albumin/globu-
lin ratio. No significant difference was found
in the percentage of children having low
albumin, globulin, or albumin/globulin ratio.
Nutritional intake for the street children
is presented in table 3. The range for each of
these items was from 0 to 7. No significant
difference was found by gender for any of
the nutritional variables. Hence, means are
reported for each type of drink or food for
males and females combined. Approximately
32% never ate pumpkin, squash, carrots, or
potatoes. On the other hand, 80% drank water
daily and 75% ate foods containing grain daily.
The relative risks for smokers vs non-
smokers of experiencing selected situations
and behaviors are presented in Table 4.
Smokers were significantly more likely to
be kicked, punched, or slapped by an adult
or peer; less likely to shower or bathe three
or more times per week, less likely to eat
dinner on a daily basis, more likely to be
sexually active; and more likely to have
consumed alcohol. After adjusting for age
and gender, smokers weighed significantly
less (31.4 vs 34.5 kg; Ρ = .0072), had lower
BMI (15.2 vs 16.3; P = .0111) and lower
respiration in one minute (23.9 vs 25.7;
Ρ = .0609). No evidence that smokers drank
or ate less than nonsmokers was found.
Of 178 children tested for hepatitis B,
14 (7.9%) tested positive. Of 179 children
tested for pneumonia, 22 (12.3%) tested
positive. Of 102 children were tested for
ascariasis, 26 (25.5 %) tested positive. No
significant difference was found between
gender or smoking in correlation with hepa-
titis B, pneumonia, or ascaris parasitic
infection prevalence.
DISCUSSION
This study describes health problems in
relation to social, environmental, and health
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behavior characteristics of street children in
Manila. Although a small percentage of
children experienced malaria or convul-
sions, episodes of coughing, fever, and
dyspnea were common problems, more so
in females than males. This finding can be
explained by male Filipino street children
being exposed to the street environment at
an earlier age and for a longer duration.
Female children in Filipino culture are
more protected and encouraged to remain
around the home, limiting their exposure to
diseases and risky health behaviors common
among street children (9). A possible expla-
nation for the high prevalence in respiratory
problems is inhalant abuse. Toluene is an
industrial solvent that is commonly inhaled
by Filipino street children and has been
proven to cause dyspnea and coughing (18).
Diarrhea was also a common problem,
which can be attributed to approximately
75% of the street children surveyed being
routinely exposed to contaminated water.
Other possible -causes of diarrhea among
the street children surveyed include con-
taminated food or child-to-child trans-
mission (19). In 2006, the Philippines
National Epidemiology Center at the
Philippines Department of Health docu-
mented diarrhea as the second leading cause
of morbidity among all ages (20).
Physical abuse has been positively
linked to increased depression, hopeless-
ness, and proneness to suicide (21). Abuse
in the form of being kicked, punched, or
slapped by an adult or a peer was a
common occurrence among street children
in this study. The frequent occurrence of
such events was much higher for males than
females. The high level of physical abuse
by an adult or peer may help explain why
above 20% of the children felt anxious or
depressed on a daily basis. Physical abuse
is also positively associated with risky
health behaviors such as smoking (22), as
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 LEVI NJORD, RM MERRILL ET AL
confirmed by the current study. Physical
abuse, which increases the risk of smoking,
may also increase the risk of other harmful
behaviors associated with smoking.
Prostitution is a common practice among
Filipino street children (8,11). Street children
are both coerced into prostitution and
practice prostitution voluntarily to earn a
living (13). Of children who were sexually
active, 36% of males and 38% of females
had received money for sex. Street life
makes prostitution especially appealing
because of limited employment opportunities
(13, 23). Prostitution exposes children to both
communicable diseases and psychological
trauma, making them especially susceptible
to ill health. Of children who were sexually
active, 61% were aware that abstaining
from sexual relations could prevent AIDS.
Males experienced significantly lower
hemoglobin and hematocrit levels than
females, relative to their gender, with many
being anemic. Anemia identified among
street children in other studies has primarily
been attributed to malnutrition (24). The
higher percentage of anemia among males
relative to females is inconsistent with the
finding that nutritional intake was similar
between the two groups. Further research is
needed to determine the cause of the
disparity in low hematocrit and hemoglobin
between genders.
Filipino street children routinely gravi-
tate together in tight social groups called
'Barkada'. This close living situation helps
explain the high prevalence of contagious
diseases like hepatitis B, pneumonia, and
ascariasis among these children. No
correlation was found between hepatitis Β
infection and sexual activity, leading to the
possibility of vertical transmission from
parents or horizontal transmission from
peers from abrasions or open lesions (25).
Possibly, the high prevalence of pneumonia
is due to close proximity while sleeping or
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373
carrying out daily tasks (25). Ascariasis can
also be attributed to the close proximity of
street children, coupled with unsanitary
environmental conditions (25). These findings
closely compare with results from a study
showing increased parasitic infections among
institutionalized Filipino street children (3).
Study limitations include participant
selection and sample collection from parti-
cipants. Randomized surveying of street
children is difficult because of their
transient lifestyle. Yet, we believe the street
children considered in this study are fairly
representative of street children in general
in Manila. Specifically, seven different
locations were randomly selected from the
different areas serviced by social workers of
Childhope-Asia Philippines (CHAP). All
children under the supervision of CHAP
within the chosen areas were included in
the study. The participants were not dis-
couraged from participating based on illness
or being under the influence of drugs.
Children were also encouraged to partici-
pate by our offering them free meals and
snacks. Many of the street children were
unable to produce a stool sample for testing
because of their malnourished state. One
child refused to have blood taken and one
child refused to have a chest radiograph.
ACKNOWLEDGMENTS
Supported by the Mary Lou Fulton Chair
for Health and Human Performance, Brigham
Young University.
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