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International Journal of Mental Health Promotion
ISSN: 1462-3730 (Print) 2049-8543 (Online) Journal homepage: http://www.tandfonline.com/loi/rijm20
Exploring age and gender differences in health risk
behaviours and psychological functioning among
homeless children and adolescents
Kwaku Oppong Asante
To cite this article: Kwaku Oppong Asante (2015) Exploring age and gender differences
in health risk behaviours and psychological functioning among homeless children and
adolescents, International Journal of Mental Health Promotion, 17:5, 278-292
To link to this article: http://dx.doi.org/10.1080/14623730.2015.1088739
Published online: 09 Dec 2015.
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Exploring age and gender differences in health risk behaviours and
psychological functioning among homeless children and adolescents
Kwaku Oppong Asante*
Discipline of Psychology, University of KwaZulu-Natal, Durban, South Africa
(Received 13 March 2015; final version received 4 August 2015)
This study describes the findings from quantitative examination of age and gender
differences in psychological problems and health risk behaviour among 227 home-
less youth. The findings indicated significant variations on health risk behaviours by
gender. As compared to males, females were more likely to engage in survival sex,
been victims of violence-rated sex, and more likely to have made a plan to commit
suicide. While alcohol use decrease with age, marijuana use and having multiple
sexual partners, on the other hand, increases with age. Approximately 87% of the
participant’s exhibit moderate-to-severe psychological problems, with males having
significantly higher scores on the overall psychological well-being, emotional and
hyperactivity problems than females. Age-group differences were also observed on
overall psychological well-being, emotional problems, conduct problems and
hyperactivity. These findings from the study are discussed with reference to previous
research and implications for interventions are provided.
Keywords: age differences; gender differences; health risk behaviours; mental
health; street children and adolescents
Introduction
Street-connected children and adolescents in sub-Saharan Africa (SSA) have poor
mental health and are vulnerable to several health risk behaviours, including high levels
of substance use, violence and sexual assault, mortality and sexual-transmitted infec-
tions including HIV and AIDS (Ahamad et al., 2014; Habtamu & Adamu, 2013;
Kayembe et al., 2008; Kudrati, Plummer, & Yousif, 2008; Mandalazi, Banda, & Umar,
2013; Nada & Suliman, 2010; Tadesse, Ayele, Mengesha, & Alene, 2013). As a vulner-
able population, street youth are generally sexually active and have early sexual debut
than the youth in the general population as their social environment may lead them to
engage in risky sexual activity and initiation of new sexual relations (Tadesse et al.,
2013; Winston et al., 2015). Research shows that the sexual activities of street connect
children and youth are often unprotected (without the use of condom), thus susceptible
to acquiring sexually transmitted infections (STIs) including HIV (Mandalazi et al.,
2013; Winston et al., 2015). Further evidence shows that having multiple sexual
partners among street youth is determined by other factors such as drug use (e.g.
alcohol, marijuana, inhalants), number of years lived on the street, early sexual debut,
social networks and being female have been documented as determinants of having
*Email: oppongasante@ukzn.ac.za
© 2015 The Clifford Beers Foundation
International Journal of Mental Health Promotion, 2015
Vol. 17, No. 5, 278–292, http://dx.doi.org/10.1080/14623730.2015.1088739
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multiple sexual partners in homeless population (Anarfi,1997; Kudrati et al., 2008;
Nada & Suliman, 2010; Tadesse et al., 2013).
In addition to engagement in health risk behaviours, homeless youth have poor
mental health and compromised psychological functioning. According to United
Nations Children’s Fund (UNICEF, 2012), the rate of mental illness among homeless
youth is very high, and two times greater than youth in the general population
(Whitbeck, 2009). A study conducted among homeless adolescents in the United States
found that about two-thirds of their sample had at least one diagnosis for a mental
health problem (Cauce et al., 2000). The authors of the same study specifically men-
tioned that 53% met the criteria for Conduct Disorder, 32% for Attention Deficit
Hyperactivity Disorder, 21% for mood disorders, 21% for mania or hypomania, 12%
for Post-Traumatic Stress Disorder and 10% for Schizophrenia (Cauce et al., 2000).
Mood disorders including major depressive disorders are also known to be prevalent
among this population. A study by Nyamathi et al. (2012) found that 53% and 33% of
the participants exhibited moderate-to-severe depressive symptoms, respectively. When
compared to males, females were more likely to be diagnosed with anxiety and
affective disorders (Slesnick & Prestopnik, 2005). Given the high prevalent rates of
emotional disorders reported in the literature, it is perhaps not surprising that there are
equally elevated rates of suicidal ideation and attempts (Frederick, Kirst, & Erickson,
2012; World Health Organization [WHO], 2011). Available data in Canada and the
United States of America showed suicide attempts to range from 20% to 86%
(Frederick et al., 2012; Kidd & Carroll, 2007; Kidd & Kral, 2002). Within SSA, few
studies have examined suicidality among homeless youth, but available evidence shows
suicide attempts to range from 20 to 32% (Swahn, Bossarte, Eliman, Gaylor, &
Jayaraman, 2010; Swahn, Palmier, Kasirye, & Yao, 2012). Among a large group of
street youth in New York and Toronto, a significant proportion (46%) of respondents
reported to have made at least one suicide attempt while on the street (Kidd & Carroll,
2007). Similarly, Swahn et al. (2012) found that approximately 31% of homeless
children who live in the slums of Kampala reported to have tried killing themselves.
These prevalence rates were higher than what was reported by Frederick et al. (2012)
in Toronto, which showed that approximately 27% and 15% of the participants reported
suicide ideation and suicide attempts, respectively, in the past year. When compared to
males, females were more likely to be susceptible to suicidal ideation and attempts
(Frederick et al., 2012).
In Ghana, there are concerns that the high number of street children and adolescent
could become a public health issue as prevalence of the phenomenon has increased
from about 35,000–90,000 within the last five years (Accra Metropolitan Assembly
(AMA), 2014). One step towards helping to reduce the health risk behaviours among
this population is to know the prevalence and the gender dimension that related to these
behaviours. Studies from various Ghanaian settings indicate that street-connected chil-
dren have less knowledge about sexuality than other youth (Anarfi,1997; Wutoh et al.,
2006), more likely to engage in unprotected sex and other high risk sexual behaviour
as a means of survival (Anarfi,1997; Oduro, 2012) and seen as a societal burden and
socially stigmatized due to their state of homelessness (Quarshie, 2011). Previous stud-
ies in Ghana are based on small sample sizes, and are more qualitative and descriptive
in nature that have been reported on the socio-demographic characteristics of street
youth, their group dynamics and survival mechanisms (Boakye-Boaten, 2008; Mizen &
Ofosu-Kusi, 2010; Orme & Seipel, 2007). In their study of street children in the west-
ern part of Ghana, Wutoh et al. (2006) found that homeless children were sexually
International Journal of Mental Health Promotion 279
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active, and suffered from both physical and sexual abuse on the street. The authors,
however, did not examine the psychological functioning of the participants in their
study, although they did suggest the need for interventions that would address both
mental health and risky sexual behaviour.
Available literature thus suggests that, the role that age and gender play in the men-
tal health of this vulnerable group of adolescents remains unexplored. There is therefore
sparse data on the health risk behaviours, as well as the age and gender dimensions
related to these behaviours among homeless population in Ghana. The main objective
of this study was to determine age and gender differences in respect to psychological
problems, and health risk behaviour, as well as outline implications for future health
promotion programmes aimed at reducing the adverse health problems associated with
homelessness.
Method
Participants and settings
The study was carried out in southern Ghana, specifically the Greater Accra region, the
smallest of the 10 administrative regions in Ghana. It occupies an area size of 3.2
square kilometres and a population of 4 million people (approximately 16%) of the
general Ghanaian population. As the capital city of Ghana, governmental ministries,
departments and agencies, corporate headquarters of international and financial institu-
tions as well as NGOs are located in Accra. The study was conducted among homeless
children and adolescents in the Central Business District of Accra, where the second
largest number of street children in Ghana can be found (Catholic Action for Street
Children, 2010). Participants were eligible to participate in the study if they met the
following inclusion criteria: (1) self-identify themselves as being homeless (i.e. live
alone or with a group of other youth on the street, have no stable place of residence
and experience movements in short periods of time), (2) able to give assent or consent
to participate in the study, and (3) not experiencing acute intoxication or obvious men-
tal health problems, or problematic behaviours. Out of 265 participants approached for
the study, 227 agreed to participate in the study, representing a response rate of 86%.
Males constitute 54% of the sample with ages ranging from 8 to 19 years with a mean
age of 12.58 (SD = 2.51). Over a third (43%) had lived on the street for a period rang-
ing from 3 to 8 years and more than half (58.9%) have had up to some basic education
(i.e. up to grade 6 or primary level). Over 59% of the participants subscribed poverty
as the main reason for them being homeless and about 25% mentioned physical and
sexual abuse as reasons. This varied by gender, χ
2
(2, N= 223) = 23.87, p< .001.
While females were more likely to report poverty (52.5%) and sexual abuse (19.8%),
boys were also like to report poverty (64.8) and physical abuse (17.2%).
Procedure
The data was collected through an interviewer-administered questionnaire due to low
levels of education among youth. The aims and objectives of the study, the voluntary
nature of participation, confidentially and anonymity of data were discussed with
participants in their preferred language (i.e. Twi and Ga –two predominant local lan-
guages spoken in Accra, Ghana), and informed consent/assent was obtained. It took an
average of 30 min to administer the full questionnaire and data collection lasted for
8 weeks. Each participant was compensated with a voucher worth approximately US
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$2.00 as a reward for participation in the study. Permission to conduct the study was
granted from the Department of Social Welfare, Accra, Ghana and the Human and
Social Science Ethics Committee, University of KwaZulu-Natal, South Africa (Ethical
Protocol number: HSS/1144/012D). None of the participants expressed the need for
psychological service, although they were told of the availability of a psychologist
should they require such a service. An experienced research assistant to each of the
participants administered the following quantitative measuring instruments.
The Strength and Difficulties Questionnaire (SDQ; Goodman, 1997), an internation-
ally validated screening tool for child and adolescent emotional and behavioural diffi-
culties was used to assess the psychological functioning of the participants. The SDQ
includes subscales for prosocial behaviour, hyperactivity, emotional, conduct and peer-
relationship problems. The SDQ is rated on a 3-point Likert scale (Not True, Somewhat
True, and Certainly True) with a score range of 0–40. The sum of the first four sub-
scales gives the total psychological difficulties per child. Scoring is classified from 0 to
15 as normal (no psychological symptoms), 16–19 as borderline (moderate psychologi-
cal symptom) and 20–40 as abnormal (severe psychological symptoms). Higher scores
on the total SDQ scale reflect poorer psychological functioning. Acceptable reliability
coefficients have been reported in Ghanaian sample (Oppong Asante & Andoh-Arthur,
2015). The Cronbach’sαfor the SDQ was .72 in this study.
Health risk behaviours, namely substance use, sexual risk behaviours, suicidal idea-
tion, and violent behaviours were measured using adapted questions from the South
African Youth Risk Behaviour Survey (Reddy et al., 2010). Four questions each were
asked to assess substance use and the frequency of suicide-related thought and beha-
viours. In these measures, higher scores related to higher levels of substance use and
suicidal ideation respectively. A violence scale consisting of 11 questions assessed
specific behaviours related to violence, violence-related and aggressive behaviours
among street children. In this study, the measures for substance use, suicidal ideation
and violent behaviours yielded Cronbach’sαvalues of .84, .75 and .72, respectively.
Participant’s sexual activity was assessed based on 4 questions enquiring into sexual
behaviour (i.e. ever had sexual intercourse, inconsistent condom use, multiple sexual
partners and engagement in survival sex).
Statistical analysis
Statistical analyses were conducted using the Statistical Package for the Social Sciences
version 21.0 for Windows (IBM SPSS Inc., Chicago IL, USA). Three age groups (7–
10 years, 11–13 years and 14 years and older) were created to ensure equal variance
between the ages. These categorizations closely correspond to late childhood, early and
late adolescence. These stages of development have distinctive features and abilities
(Cauce et al., 2000; UNICEF, 2011). Chi-square (χ
2
) analysis was used to examine gen-
der and age-group difference on individual items measuring sexual risk behaviour, sui-
cidal ideations, violence and substance abuse. A One-Way ANOVA was used to
determine the effect of age groups on the psychological problems (as measured by
SDQ), and where necessary, post hoc analysis, specifically (Turkey-HSD) was used to
examine where specific differences exist with regards to age groups on the various psy-
chological problems. The independent samples t-test was used to examine whether male
and females differ on the various psychological problems, and Cohen d effect size was
used to measure the magnitude of such differences where they exist. All analyses were
two-tailed, and a p-value of less than .05 was considered statistically significant.
International Journal of Mental Health Promotion 281
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Results
Substance use, sexual risk behaviour, violence and violent-related behaviours and
suicidal behaviour among street children and youth, and how they vary according to
gender and age-groups are presented in Tables 1and 2. The results are presented with
reference to the specific health risk behaviour.
Substance use/abuse
Substance use was relatively high among the sample in this study. The results as pre-
sented in Table 1showed that over 66.2% of the sample reported to have ever smoked
cigarettes, 81.3% reported having used alcoholic beverages, out of which 70.1% had
used alcohol in the preceding month to the study. Approximately 72% indicated to have
ever smoked marijuana. There was a statistical significant gender difference in sub-
stance use in this study. As compared to males, females (73.4 vs. 60.3%) were more
likely to have smoked cigarettes [χ
2
(1, N= 139) = 3.96, p< .05], drunk alcoholic
beverages (90.1 vs. 73.7%), [χ
2
(1, N= 178) = 9.58, p= .002] and more likely to have
ever used marijuana (79.0 vs. 65.5%), [χ
2
(1, N= 149) = 4.73, p< .05].
The results in Table 2also revealed age-group differences in relation to substance
use. Alcohol use in the last month varied by age, [χ
2
(2, N= 146) = 12.08, p= .002].
Table 1. Gender differences in health risk behaviours.
Risk behaviours
Total
N(%)
Males
N(%)
Females
N(%) χ
2
(p-values)
Substance abuse/misuse items
Smoked cigarette 139 (66.2) 70 (60.3) 69 (73.4) .047
Had drunk an alcoholic beverage 178 (81.3) 87 (73.7) 91 (90.1) .002
Alcohol use in the last one month 147 (70.1) 76 (66.7) 71 (75.5) .162
Ever used marijuana (wee) 149 (72.0) 70 (65.5) 79 (79.0) .030
Sexual risk behaviour items
Sexually active in the last one month 151 (69.3) 74 (63.2) 77 (76.2) .038
Condom use in last sexual activity 37 (17.1) 17 (14.5) 20 (20.2) .225
Multiple sexual partners (i.e. two or more) 118 (54.9) 58 (50.0) 60 (60.2) .119
Transactional sex/or survival sex 115 (53.0) 52 (44.8) 63 (62.4) .010
Violence items
Ever forced to have sex 71 (32.6) 25 (20.7) 46 (47.4) <.001
Ever forced someone to have sex 62 (28.6) 32 (26.7) 30 (30.9) .490
Know someone who had been raped 124 (57.1) 67 (55.8) 57 (58.8) .665
Injured in a fight 162 (74.3) 96 (79.3) 66 (68.0) .058
Ever been bullied 195 (90.7) 106 (90.6) 89 (90.8) .956
Bullied someone 136 (63.3) 68 (58.1) 68 (69.4) .088
Beaten someone? 136 (63.6) 69 (59.0) 67 (69.1) .127
Ever been beaten 190 (89.6) 106 (92.2) 84 (86.6) .185
Ever been robbed 172 (81.1) 84 (73.4) 88 (89.9) .003
Assaulted with a weapon 146 (67.9) 74 (63.8) 72 (72.8) .162
Threatened with a weapon? 141 (66.2) 72 (62.1) 69 (71.1) .164
Suicidal ideation
Feelings of hopelessness 181 (84.6) 103 (87.3) 78 (81.3) .224
Attempted suicide 59 (27.6) 28 (23.7) 31 (32.3) .163
Planned to commit suicide 56 (26.2) 23 (19.5) 33 (34.4) .014
Made one or two suicide attempts 60 (28.0) 24 (20.3) 36 (37.5) .005
Note: Statistical significant pvalues in bold.
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Street children aged (11–13 years) reported using alcohol (81.1%) more than those aged
(14–19) years (71.4%) and (7–10)-year-olds (52.3%). Participants aged 11–13 years
(92.6%) were more likely to have reported ever drinking alcohol than those aged
14–19 years (83.6%) and 7–10 years (59.6%), [χ
2
(2, N= 177) = 23.73, p< .001].The
findings therefore suggest that early adolescents were more likely to have ever drunk
and used alcohol compared to both those in their late childhood and late adolescence
years in the study. The results further shows that the use of marijuana increases with
age, [χ
2
(2, N= 148) = 6.33, p< .05]. Late adolescents (14–19 years) were most likely
to have used marijuana (77.3%), followed by early adolescents (11–13 years) (76.0%)
and those in their late childhood (7–10 years) (57.1%).
Table 2. Age differences in health risk behaviours.
Risk behaviours
Total
N(%)
7–10 years
N(%)
11–13 years
N(%)
14–19 years
N(%)
χ
2
(p-values)
Substance abuse/misuse items
Smoked cigarette 138 (67.0) 27 (58.7) 60 (68.2) 51 (70.8) .365
Had drunk an alcoholic
beverage
177 (82.3) 28 (59.6) 88 (92.6) 61 (83.6) <.001
Alcohol use in the last one
month
146 (71.6) 23 (52.3) 73 (81.1) 50 (71.4) .002
Ever used marijuana (wee) 148 (72.5) 24 (57.1) 73 (76.0) 51 (77.3) .042
Sexual risk behaviour items
Sexually active in the last
one month
150 (69.8) 24 (51.1) 75 (78.1) 51 (70.8) .001
Condom use in last sexual
activity
37 (17.4) 5 (10.6) 18 (18.9) 14 (19.7) .385
Multiple sexual partners (i.e.
two or more)
117 (55.2) 16 (34.0) 56 (60.2) 45 (62.5) .001
Transactional sex/or survival
sex
115 (53.3) 15 (31.9) 51 (53.7) 48 (66.7) .004
Violence items
Ever forced to have sex 69 (32.2) 13 (26.5) 28 (29.5) 28 (40.0) .109
Ever forced someone to have
sex
61 (28.6) 9 (18.4) 24 (25.5) 28 (40.0) .025
Know someone who had
been raped
122 (57.7) 29 (59.2) 49 (52.1) 45 (64.3) .085
Injured in a fight 160 (74.8) 44 (89.8) 61 (63.5) 55 (79.7) .010
Ever been bullied 192 (91.0) 44 (97.8) 86 (90.5) 62 (87.3) .112
Bullied someone 135 (64.0) 23 (51.1) 59 (62.1) 53 (74.6) .032
Beaten someone? 136 (64.8) 27 (60.0) 55 (58.5) 54 (76.1) .049
Ever been beaten 187 (89.5) 41 (89.1) 83 (88.3) 63 (91.3) .390
Ever been robbed 170 (81.7) 30 (66.7) 83 (89.2) 57 (81.4) .006
Assaulted with a weapon 144 (68.2) 24 (53.3) 70 (73.7) 50 (70.4) .048
Threatened with a weapon? 139 (66.2) 25 (55.6) 68 (71.6) 46 (65.7) .119
Suicidal ideation
Feelings of hopelessness 178 (84.8) 44 (95.7) 74 (81.3) 60 (82.2) .063
Attempted suicide 59 (28.1) 16 (34.8) 35 (38.5) 8 (11.0) <.001
Planned to commit suicide 55 (26.2) 14 (30.4) 31 (34.1) 10 (13.7) .010
Made one or two suicide
attempts
60 (28.6) 18 (39.1) 27 (29.7) 15 (20.5) .110
Note: Statistical significant pvalues in bold.
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Sexual risk behaviours
Concerning street children and adolescents sexual behaviours, the majority (69.3%)
were sexually active. This varied according to gender, [χ
2
(1, N= 151) = 4.30, p< .05],
and age groups, [χ
2
(2, N= 150) = 14.54, p< .001]. Females (76.2%) were more likely
to be sexually active than males (63.2%) in the last month prior to the study. Early ado-
lescents (11–13 years) were more likely to be sexually active (78.1%), followed by late
adolescents (14–19 years) (70.8%) and those in their late childhood (7–10 years)
(51.1%). The results also revealed that the majority of the participants had not used
condoms as only 17.1% indicated to have used condoms in their last sexual activity
over the past one month. Over half (54.9%) had more than two lifetime sexual partners.
This varied according to age groups, [χ
2
(2, N= 117) = 11.00, p= .004], and the num-
ber of sexual partners increased with age. Late adolescents (14–19 years) (62.5%) were
more likely to have multiple sexual partners than both early adolescents (60.2%) and
late childhood (34.0%). Overall, 53% of the street children have had sex in exchange
for food, money, clothes or even a place to sleep, with females (62.4%) more likely to
engage in such behaviours than boys (44.8%) [χ
2
(1, N= 115) = 6.68, p< .05]. This
behaviour also increased with age: the older the participant the more likely they
reported to have engaged in such health risk behaviour, [χ
2
(2, N= 115) = 13.81,
p= .001].
Violent behaviour
With regards to violence, this study showed that 66.2% of the participants reported that
they had been threatened with a weapon and 67.9% have been assaulted with a
weapon, such as a knife, stick or some other sharp objects such as blades. During the
past one month, 90.7% of the participants had been bullied and approximately 9 out of
10 have been beaten up on the street. The majority (81.1%) of the participants indi-
cated to have been robbed on the street, but more females (89.9%) had been robbed on
the street than boys (73.9%), [χ
2
(1, N= 172) = 9.93, p< .01]. In terms of coerced sex,
roughly 1 in 3 street youth have been forced to have sex with someone, with females
(47.4%) more likely to be victims than males (20.7%), [χ
2
(1, N= 71) = 17.56,
p< .001]. Over 75% know someone who has been raped, and 28.6% of the street chil-
dren had coerced someone to have sex against their will. As presented in Table 2, age-
group differences existed on violent and violence-related behaviours of the participants
in the study. Incidence of forcing someone to have sex, [χ
2
(2, N= 61) = 7.40,
p< .05]; and bullying someone, [χ
2
(2, N= 135) = 6.89, p< .05], were found to
increase with age. The results further revealed significant age-group differences in ever
being injured in a fight, χ
2
(2, N= 160) = 13.17, p= .001], ever beaten someone,
[χ
2
(2, N= 136) = 6.03, p< .05]; having been robbed χ
2
(2, N= 170) = 10.06, p= .006
and being assaulted with a weapon [χ
2
(2, N= 144) = 6.07, p< .05].
Suicidal ideation
The study also revealed moderate levels of suicidal ideation and suicide attempts as
shown in Table 1. Approximately 85% had feelings of hopelessness about the future
during the past one month, and 27.6% reported to ever having considered attempting
suicide. Only 26.2 and 28.0% reported to have made a plan to commit suicide or
attempted suicide on one or two occasions respectively. This varied according to gender:
females were more likely to have made a plan to commit suicide than males,
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[χ
2
(1, N= 56) = 6.07, p< .05], and were more likely to have made one or two suicide
attempts, [χ
2
(1, N= 60) = 7.73, p= .005]. The results as presented in Table 2also
revealed that age-group differences exist in considering to commit suicide, [χ
2
(2,
N= 59) = 16.47, p< .001], and having planned to commit, [χ
2
(2, N= 60) = 9.24,
p< .05]. When compared to the other age-groups, late adolescents (14–19 years) were
less likely to have considered attempting suicide (11.0%) and made a plan to commit
suicide (13.7%). Over 38.5% of the 11–13-year-olds and 34.8% of the 7–10-year-olds
indicated to have considered attempting suicide. Additionally, a lot more of
11–13-year-olds (34.1%) and 30.4% of 7–10-year-olds reported to have made a plan to
commit suicide.
Gender and age-group differences in psychological functioning
Gender differences in psychological functioning
The general psychological functioning of the participants in the study was very high,
with approximately 87% exhibiting moderate-to-severe psychological problems. Emo-
tional problems were reported by 68.9%, conduct problems by 73.8%, hyperactivity/
inattention problems by 53.9%, and 88.6% reported peer-relationship problems. Gender
differences were observed in overall psychological functioning (Total SDQ score), emo-
tional problems and hyperactivity. As shown in Table 3, male participants (M= 21.9,
SD = 6.31) showed worse psychological functioning than females (M= 19.65,
SD = 5.77); [t(206) = 2.62, p< .01, d= .37]. Emotional problems were significantly
higher in males (M= 7.33, SD = 2.25) than females (M= 6.33, SD = 2.45), [t(206)
= 3.14, p< .01, d= .45]. The results also revealed a statistical significant difference in
hyperactivity problems, [t(206) = 2.23 p< .05, d= .32]. Males (M= 5.66, SD = 2.16)
were found to exhibit more hyperactive problems than females (M= 4.98, SD = 2.14).
Even though males (M= 5.16, SD = 2.94) had more conduct problems than females
(M= 4.98, SD = 2.92), this difference was not strong enough to yield any statistical
significance, [t(206) = 1.08, p> .05].
Age group differences in psychological functioning
The one-way between-groups ANOVA was used to determine whether there were any
differences between the 3 age groups on psychological functioning. The results as
Table 3. Means and standard deviations of psychological functioning for male and female
homeless youth in the study.
Variable
Male
(N= 117)
Female
(N= 99)
t-value
95% CI
d-valueMean SD Mean SD LL UL
Total difficulties score 21.90 6.31 19.65 5.77 2.62
**
.56 3.95 .37
Emotional symptoms 7.33 2.25 6.33 2.45 3.14
**
.37 1.63 .45
Conduct problems 5.16 2.94 4.71 2.93 1.08 −.37 1.27 .15
Hyperactivity/inattention 5.66 2.16 4.98 2.14 2.23
*
.07 1.28 .32
Peer relationships problems 4.85 1.45 4.86 1.43 .69 −.42 .39 .09
Note: 95% Confidence interval (CI) for the mean difference; Cohen dis the effect size for the t-test values;
LL –lower limits and UL –Upper limit.
*p< .05; **p< .01.
International Journal of Mental Health Promotion 285
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presented in Table 4shows that there is a statistical significant difference in overall
psychological functioning among the 3 age groups, [F(2, 195) = 9.19, p< .01]. Multi-
ple comparisons, using Turkey HSD indicated that the mean score for 11–13-year-olds
(M= 18.81, SD = 6.11) were significantly different from both 7–10-year-olds
(M= 22.28, SD = 5.35), p= .001, and the 14–19-year-olds (M= 22.45, SD = 5.97),
p= .002. There was a significant difference in emotional problems [F(2, 212) = 3.38,
p< .05], conduct problems [F(2, 210) = 11.63, p< .01] and hyperactivity [F(2, 211)
= 3.33, p< .05] among the three age groups of participants in the study. Further
multiple comparison analysis on emotional symptoms showed that the mean score for
11–13-year-olds (M= 6.33, SD = 2.27) was different from that of the 14–19-year-olds
(M= 7.14, SD = 2.08). This mean difference approached statistical significance,
p= .059. With regards to conduct problems, multiple comparison results showed that
mean score for the 11–13-year-olds (M= 4.00, SD = 2.97) was significantly different
from the mean score of those 7–10-years-old (M= 5.67, SD = 2.67), p= .002; and
14–19-years-old (M= 5.97, SD = 2.48), p> .001. There was however, no difference in
the mean scores of 7–10-year-olds (M= 5.67, SD = 2.67) and 14–19-year-olds
(M= 5.97, SD = 2.48) on conduct problems. The results as presented in Table 4further
shows that with regards to hyperactivity among the participants, a statistical significant
difference exist between 7- and 10 year olds (M= 5.90, SD = 2.02) and the
11–13-year-olds (M= 4.99, SD = 1.92), p> .05.
Discussion
The main objective of this study was to determine age and gender differences in respect
to psychological problems, and health risk behaviour. The findings of the study showed
that more females had smoked cigarettes, used alcohol and marijuana than males in the
past month. This finding contradicts previous studies among homeless youth where
males generally reported higher substance use than females (Ahamad et al., 2014;
Habtamu & Adamu, 2013; Hadland et al., 2011; Kayembe et al., 2008). The sex differ-
ence may possibly be attributed to the fact that female adolescents with sexual abuse
histories are more likely to abuse drugs on the street (Chen, Tyler, Whitbeck, & Hoyt,
Table 4. Psychological functioning of homeless youth according to age groups (N= 223).
Variable
7–10 years
(N= 50)
11–13 years
(N= 98)
14–19yrs
(N= 75)
F
values
Post hoc
comparisons
[1] [2] [3]
Mean SD Mean SD Mean SD
Total difficulties
score
22.38 5.35 18.81 6.11 22.45 5.97 9.19
***
[1 > 2]
***
,
[3 > 2]
**
Emotional symptoms 7.12 2.47 6.33 2.27 7.14 2.08 3.38
*
[1 > 2]
*
Conduct problems 5.67 2.67 4.00 2.97 5.93 2.48 11.63
***
[1 > 2]
**
,
[3 > 2]
***
Hyperactivity/
inattention
5.90 2.02 4.99 2.30 5.57 1.92 3.33
*
[1 > 2]
*
Peer problems 4.80 1.34 4.84 1.61 4.99 1.22 3.18 N/A
Note: 7–10 years (late childhood); 11–13 years (early adolescence) and 14–19 years (late adolescence).
*p< .05; **p< .01; ***p< .001.
286 K. Oppong Asante
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2004). In this study, more females reported sexual abuse as a reason for being homeless
than male participants. The extent of their engagement in survival sex is possibly linked
to supporting their substance use behaviours.
There were significant variations on sexual behaviour, violent behaviour, and sui-
cide ideation by gender. Females showed more engagement in health risk behaviour
and suicidal behaviours than males. Compared to males, females were more likely to
engage in transactional/survival sex, be victims of violence-related sex, likely to have
made a plan to commit suicide and attempted suicide. These findings are supported in
other studies (Gwadz, Nish, Leonard, & Strauss, 2007; Kidd & Carroll, 2007; Oduro,
2012). As in the general population with adolescent females, street girls in this study
have reported more suicidal attempts and higher levels of suicidal ideation than their
male counterparts. This could be attributed to the heightened levels of risk females are
exposed to on the street. According to Oduro (2012), young street girls suffer from
psychological and emotional effects of rape, compounded by keeping these experiences
to themselves (without sharing it) due to the associated stigma. This may likely
increase their state of depression and suicidality.
Other contextual factors that could have influenced the likelihood for female street
youth to have had sex for money and coerced to have sex include the harsh conditions
of life on the street as it may be at times unbearable for the girls, and since finding a
source of income is very difficult, the high rate of commercialization of sex could be a
plausible reason. Additionally, power dynamics on the street could play a role, due to
the female’s subservient position to men in an African society (Epele, 2002; Oduro,
2012). Ghanaian women often experience relative powerlessness, compared to men,
because of low economic empowerment and traditional social norms (Wutoh et al.,
2006). As a result, they often submit to the will of their male counterpart/
boyfriends/sexual partners. This unequal power relationship with men, generally, along
with limited life choices on the street, could make female street youth vulnerable to
sexual advances through the use of violence to have sex.
While early adolescents were more likely to abuse alcohol than the other age
groups, marijuana use increased with age. Early adolescence as a stage of development
is characterized with experimentation (Sumter, Bokhorst, Steinberg, & Westenberg,
2009), and is likely to explain the vulnerability of this group to experiment with alco-
hol which is generally accessible to both minors and adults in Ghana (Adu-Mireku,
2003). The increase of marijuana use with age is not surprising as it is against the law
and not easily accessible, so homeless youth have to develop various mechanisms to
access it. This finding is also suggestive of the fact that the longer youth live on the
street, the more likely they are to engage in substance use including marijuana because
the experiences of homelessness render them vulnerable to substance use (Embleton,
Ayuku, Atwoli, Vreeman, & Braitstein, 2012; Hodgson, Shelton, van den Bree, & Los,
2013). Social estrangement, that occurs when street youth become deep-rooted in street
life with time, may also explain youth susceptibility with increasing age to engage in
more high-risk behaviours including substance use (Bender et al., 2012). Substance use
with increased age may be associated with increased sexual risk sexual behaviours, as
reported by previous study with the sample population (Oppong Asante, Meyer-Weitz,
& Petersen, 2014).
The results of the study revealed that the overall psychological well-being, emo-
tional, and hyperactivity problems varied by gender, with males most often fitting into
the criteria for these mental health problems. These findings support previous studies
conducted in developed countries such as Canada and the Unites States of America
International Journal of Mental Health Promotion 287
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(Cauce et al., 2000; Slesnick & Prestopnik, 2005), but contradicts a study conducted
by Rice, Tulbert, Cederbaum, Adhikari, and Milburn (2012), which reported that
female homeless youth generally suffer more from depressive symptoms and other
psychological problems than their male counterparts. In an extensive literature review,
Edidin, Ganim, Hunter, and Karnik (2012) reported that the experience of homelessness
appears to influence both mental and physical health of street youth. Whilst males and
female homeless youth are known to differ on externalising and internalising problems
(Slesnick & Prestopnik, 2005), the results seem to suggest that males significantly
suffer from both internalising (i.e. emotional problems) and externalising problem (i.e.
hyperactivity) behaviours in this study.
Age-group differences were observed in four out of the five indexes of psychologi-
cal well-being among the participants. Late childhood and late adolescent youth experi-
enced higher psychological problems than their counterparts in early adolescence. What
seems to be an obvious trend in the results was that psychological symptoms seems to
be very high at late childhood, remains stable at early adolescence, and then peaks
again at late adolescence. Taking into consideration that fact that these participants
come from troubled families, and most often left home due to physical and sexual
abuse, it is expected that this would have resulted in some form of behavioural and
emotional problems as evidenced in the study participants. The findings confirm that of
a previous study’sfindings conducted by Cauce et al. (2000), where no consistent
pattern of age differences in psychological symptoms was found.
Implications for interventions
The findings revealed that substance use increases with age, which means that as home-
less youth become older, they would be more likely to engage in substance abuse and
abuse. It is therefore important for NGOs and international organizations that provide
psycho-social services for homeless youth to target early entrants to the street before
they become entrenched in the street subculture which is characterized with violence,
substance abuse and sexual risky behaviours. This could be done by initiating harm
reduction programmes that would address the needs of this population by ensuring that
they use condoms correctly and consistently when engaging in sexual intercourse, espe-
cially for those who have multiple sexual partners. This initiative could use previously
successful street youth to act as peer educators, as peer-to-peer contact has proven to
be one of the effective approaches to reaching most-at-risk young people (UNAIDS
Inter-Agency Task Team on HIV & Young People, 2010).Cognizance of gender dimen-
sions is important in developing interventions for homeless population. A client-centred
approach could be used through the development of trust when dealing with psychoso-
cial problems, especially in respect of females who might have been sexually abused or
involved in some form of survival sex. On the contrary, since males are known to be
perpetrators of sexual violence on the street (Cauce et al., 2000), programmes must
focus on reducing or limiting such abuses.
Help-seeking behaviour for health and mental problems are important to foster an
understanding of the need to seek help timeously is important. Knowledge of and
access to services should be a key focus of interventions. Homeless youth’s ability to
seek and access help for the various health and mental risk behaviours that they are
predisposed to would reduce the burden of disease on their mental and psychical
health. There is also the need for intervention programmes to address the social and
contextual determinants that impact on the youth’s mental health status. Access to
288 K. Oppong Asante
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interventions and services are critical for homeless youth as they are vulnerable to
engage in a range of risk behaviours directed at survival with detrimental consequences
to their health and well-being. Health promotion interventions which address health risk
behaviours, for example, risky sexual behaviours, violence-related behaviours and sub-
stance use and abuse are critical among this group as they are vulnerable to unintended
pregnancies, STIs including HIV and AIDS, substance abuse disorders and other related
conditions. The cumulative effects of multiple risk behaviours should be emphasized,
especially among early entrants to the street before they become familiarized with the
street subculture which is characterized by violence, abuse and risky sexual behaviours.
Strengths and limitations
One of the major strengths of this study is this is the only study within the African
context to have documented in detail age and gender differences in both health risk
behaviour and psychological functioning of street-connected children and youth.
Another is the relatively large proportion of female street youth, one of the largest in
current literature within SSA. Beside these strengths, this study may have some limita-
tions. The findings of this study must be interpreted cautiously, as several issues might
have introduced bias in this study, primarily the cross-sectional design used for this
study. The cross-sectional nature of the research means that cause-and-effect relation-
ship cannot readily be established; however, a cross-sectional study has the advantage
of being able to study a large group of people at a single point in time, and thus evalu-
ate prevalence. Additionally, the measures are based on homeless youth self-report,
which might be a source of systematic bias. The researcher, however, believes that if
there was any reporting bias, the direction was under reporting rather than over report-
ing of the substance use and sexual behaviour, especially for male participants.
Conclusion
This study examined the age and gender difference in both mental health and health
risk behaviours of street-connected children and adolescents. There were significant
variations on health risk behaviours by gender. As compared to males, more females
were likely to engage in survival sex, been victims of violence-rated sex, and more
likely to have made a plan to commit suicide. While alcohol use decreases with age,
marijuana use, on the other hand, increases with age. The results further showed that
the overwhelmingly majority of the participant’s exhibit moderate-to-severe psychologi-
cal problems, with males having significantly higher scores on the overall psychological
well-being, emotional and hyperactivity problems than females. Age-group difference
was also observed on overall psychological well-being, emotional problems, conduct
problems and hyperactivity. Despite the limitations associated with cross-sectional stud-
ies, this finding adds to the knowledge about the poor psychological health and ele-
vated levels of health risk behaviours among street children and adolescents in this
Ghanaian setting. These findings highlight the need for interventions aimed at reducing
harm associated with homelessness as found in this study. Further studies are needed
within the African context to examine more clearly the clustering effect of health risk
behaviours, with more emphasis on their impact on HIV and mortality risks for home-
less youth. Examining these variables longitudinally would also prove informative in
establishing the directionality of the interrelationships between variables.
International Journal of Mental Health Promotion 289
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ORCID
Kwaku Oppong Asante http://orcid.org/0000-0002-0206-3326
References
Accra Metropolitan Assembly (AMA). (2014). Census on street children in the Greater Accra
region. Accra: Author.
Adu-Mireku, S. (2003). The prevalence of alcohol, cigarette, and marijuana use among Ghanaian
senior secondary students in an urban setting. Journal of Ethnicity in Substance Abuse, 2,
53–65.
Ahamad, K., DeBeck, K., Feng, C., Sakakibara, T., Kerr, T., & Wood, E. (2014). Gender
influences on initiation of injecting drug use. The American Journal of Drug and Alcohol
Abuse, 40, 151–156.
Anarfi, J. K. (1997). Vulnerability to sexually transmitted disease: Street children in Accra.
Health Transit Review, 7, 281–306.
Bender, K., Thompson, S. J., Ferguson, K., Komlo, C., Taylor, C., & Yoder, J. (2012). Substance
use and victimization: Street-involved youths’perspectives and service implications. Children
and Youth Services Review, 34, 2392–2399.
Boakye-Boaten, A. (2008). Street children: Experiences from the streets of Accra. Research
Journal of International Studies, 8,76–84.
Catholic Action for Street Children. (2010). The Ghanaian street child. Accra, Ghana: Author.
Cauce, A. M., Paradise, M., Ginzler, J. A., Embry, L., Morgan, C. J., Lohr, Y., & Theofelis, J.
(2000). The characteristics and mental health of homeless adolescents: Age and gender
differences. Journal of Emotional and Behavioural Disorders, 8, 230–239.
Chen, X., Tyler, K. A., Whitbeck, L. B., & Hoyt, D. R. (2004). Early sexual abuse, street
adversity, and drug use among female homeless and runaway adolescents in the Midwest.
Journal of Drug Issues, 34(1), 1–21.
Edidin, J. P., Ganim, Z., Hunter, S. J., & Karnik, N. S. (2012). The mental and physical health of
homeless youth: A literature review. Child Psychiatry & Human Development, 43, 354–375.
Embleton, L., Ayuku, D., Atwoli, L., Vreeman, R., & Braitstein, P. (2012). Knowledge, attitudes,
and substance use practices among street children in Western Kenya. Substance Use and
Misuse, 47, 1234–1247.
Epele, M. E. (2002). Gender, violence and HIV: Women’s survival in the streets. Culture,
Medicine and Psychiatry, 26,33–54.
Frederick, T. J., Kirst, M., & Erickson, P. G. (2012). Suicide attempts and suicidal ideation
among street-involved youth in Toronto. Advances in Mental Health, 11,8–17.
Goodman, R. (1997). The strengths and difficulties questionnaire: A research note. Journal of
Child Psychology and Psychiatry, 38, 581–586.
Gwadz, M. V., Nish, D., Leonard, N. R., & Strauss, S. M. (2007). Gender differences in trau-
matic events and rates of post-traumatic stress disorder among homeless youth. Journal of
Adolescence, 30,117–129.
Habtamu, D., & Adamu, A. (2013). Assessment of sexual and reproductive health status of street
children in Addis Ababa. Journal of Sexually Transmitted Diseases, 2013,1–20.
Hadland, S. E., Marshall, B. D., Kerr, T., Zhang, R., Montaner, J. S., & Wood, E. (2011). A
comparison of drug use and risk behavior profiles among younger and older street youth.
Substance Use and Misuse, 46, 1486–1494.
Hodgson, K. J., Shelton, K. H., van den Bree, M. B., & Los, F. J. (2013). Psychopathology in
young people experiencing homelessness: A systematic review. American Journal of Public
Health, 103, e24–e37.
Kayembe, P. K., Mapatano, M. A., Fatuma, A. B., Nyandwe, J. K., Mayala, G. M., Kokolomami,
J. I., et al. (2008). Knowledge of HIV, sexual behaviour and correlates of risky sex among
street children in Kinshasa, Democratic Republic of Congo. East African Journal of Public
Health, 5, 186–192.
Kidd, S. A., & Carroll, M. R. (2007). Coping and suicidality among homeless youth. Journal of
Adolescence, 30, 283–296. doi:10.1016/j.adolescence.2006.03.002
Kidd, S. A., & Kral, M. J. (2002). Street youth suicide and prostitution: A qualitative analysis.
Adolescence, 37,411–430.
290 K. Oppong Asante
Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 04:30 09 December 2015
Kudrati, M., Plummer, M. L., & Yousif, N. D. E. H. (2008). Children of the sug: A study of the
daily lives of street children in Khartoum, Sudan, with intervention recommendations. Child
Abuse and Neglect, 32, 439–448.
Mandalazi, P., Banda, C., & Umar, E. (2013). Street children’s vulnerability to HIV and sexually
transmitted infections in Malawian cities. Malawi Medical Journal, 25(1), 1–4.
Mizen, P., & Ofosu-Kusi, Y. (2010). Asking, giving, receiving: Friendship as survival strategy
among Accra’s street children. Childhood, 17, 441–454.
Nada, K. H., & Suliman, E. D. A. (2010). Violence, abuse, alcohol and drug use, and sexual
behaviors in street children of Greater Cairo and Alexandria, Egypt. AIDS, 24, S39–S44.
Nyamathi, A., Marfisee, M., Slagle, A., Greengold, B., Liu, Y., & Leake, B. (2012). Correlates
of depressive symptoms among homeless young adults. Western Journal of Nursing
Research, 34,97–117.
Oduro, G. Y. (2012). ‘Children of the street’: Sexual citizenship and the unprotected lives of
Ghanaian street youth. Comparative Education, 48,41–56.
Oppong Asante, K., & Andoh-Arthur, J. (2015). Prevalence and determinants of depressive
symptoms among university students in Ghana. Journal of Affective Disorders, 171, 161–166.
Oppong Asante, K., Meyer-Weitz, A., & Petersen, I. (2014). Substance use and risky sexual
behaviours among street connected children and youth in Accra, Ghana. Substance Abuse
Treatment Prevention, and Policy, 9,45–53.
Orme, J., & Seipel, M. M. O. (2007). Survival strategies of street children in Ghana: A
qualitative study. International Social Work, 50, 489–499.
Quarshie, E. N. B. (2011). Public’s perceptions of the phenomenon of street children: A qualita-
tive study of students and shopkeepers in Accra, Ghana. (Master’s thesis). Norwegian
University of Science and Technology Trondheim, Norway. Retrieved April 20, 2013.
Reddy, S. P., James, S., Sewpaul, R., Koopman, F., Funani, N. I., Sifunda, S., Josei, J., Masuka,
P., Kambaran, N. S., & Ormardien, R. G. (2010). Umthente Uhlaba Usamila –The 2nd
South African national youth risk behaviour survey 2008. Cape Town, South Africa: South
African Medical Research Council.
Rice, E., Tulbert, E., Cederbaum, J., Adhikari, A. B., & Milburn, N. G. (2012). Mobilizing
homeless youth for HIV prevention: A social network analysis of the acceptability of a face-
to-face and online social networking intervention. Health Education Research, 27, 226–236.
Slesnick, N., & Prestopnik, J. (2005). Dual and multiple diagnoses among substance using run-
away youth. The American Journal of Drug and Alcohol Abuse, 31, 179–201.
Sumter, S. R., Bokhorst, C. L., Steinberg, L., & Westenberg, P. M. (2009). The developmental
pattern of resistance to peer influence in adolescence: Will the teenager ever be able to resist?
Journal of Adolescence, 32, 1009–1021.
Swahn, M. H., Bossarte, R. M., Eliman, D. M., Gaylor, E., & Jayaraman, S. (2010). Prevalence
and correlates of suicidal ideation and physical fighting: A comparison of students in Bots-
wana, Kenya, Uganda, Zambia and the Unites States. International Public Health Journal, 2,
195–205.
Swahn, M. H., Palmier, J. B., Kasirye, R., & Yao, H. (2012). Correlates of suicide ideation and
attempt among youth living in the slums of Kampala. International Journal of Environmental
Research and Public Health, 9, 596–609.
Tadesse, N., Ayele, T. A., Mengesha, Z. B., & Alene, K. A. (2013). High prevalence of HIV/
AIDS risky sexual behaviors among street youth in gondar town: A community based cross
sectional study. BMC Research Notes, 6, 234–239.
UNAIDS Inter-Agency Task Team on HIV and Young People. (2010). Young people most at risk
of HIV: A meeting report and discussion paper from the interagency youth working group.
Research Triangle Park, NC: FHI.
United Nations Children’s Fund (UNICEF). (2011). Focus on early-and-late-adolescence.
Retrieved November 8, 2014, from www.unicef.org/sowc2011/pdfs/Early-and-late-adoles
cence.pdf
United Nations Children’s Fund (UNICEF). (2012). The state of the World’s Children 2012:
Children in an urban World. New York, NY: Author.
Whitbeck, L. B. (2009). Mental health and emerging adulthood among homeless young people.
New York, NY: Psychology Press.
International Journal of Mental Health Promotion 291
Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 04:30 09 December 2015
Winston, S. E., Chirchir, A. K., Muthoni, L. N., Ayuku, D., Koech, J., Nyandiko, Carter, E. J., &
Braitstein, P. (2015). Prevalence of sexually transmitted infections including HIV in
street-connected adolescents in western Kenya. Sexually Transmitted Infections, 1–7.
World Health Organization (WHO). (2011). Suicide prevention (SUPRE). Retreived October 11,
2014, from http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
Wutoh, A. K., Kumoji, E. K., Xue, Z., Campusano, G., Wutoh, R. D., & Ofosu, J. R. (2006).
HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana. AIDS and
Behavior, 10, 209–215.
292 K. Oppong Asante
Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 04:30 09 December 2015
