The correlation between dysfunctional family process and self-neglect of street children at Special Region of Yogyakarta

The correlation between dysfunctional family process and self-neglect of street children at Special Region of Yogyakarta Kellyana Irawati1*, Fadjri Nuryusofa Ningrat2, Eltanina Ulfameytalia Dewi3 Introduction: Street children still become a big concern in the world, and United Nations has concerns about a homeless child or live-in poverty. Dysfunction of the family process has the worst implication for the child as a vulnerable population. It does not only increase anxiety and depression but also leads to self-neglect especially among street children. The nurse especially the mental health nurse and community nurse needs to identify the risk factor of dysfunctional family process and self-neglect to make possible prevention and intervention for street children. This study aims to determine the correlation between the dysfunction of the family process and the self-neglect of street children in Yogyakarta. Methods: The sample was 90 street children who are from the district in Yogyakarta. The sample was taken by accidental sampling technique, with the sampling criteria: 1) the street children who live in Yogyakarta, 2) willing to fill inform consent, 3) both boys or girls, 4) age 10-21 years old, 5) not marriage yet. The instrument was using a dysfunction of family process questionnaire and self-neglect questionnaire which are both are developed from NANDA-I Nursing Diagnoses. The data analysis was used Pearson Correlation Test. Results: The mean score of dysfunctions of the family process is 109 and self-neglect has a mean score of 28.33. There was a significant relationship between dysfunction of family process and self-neglect among street children in Yogyakarta (p= 0.000) with a correlation coefficient were 0.659. Conclusions: There was a significant relationship between dysfunction of family process and self-neglect among street children in Yogyakarta.


INTRODUCTION
Families are groups of two or more individuals who are related by blood, marriage, or adoption and who live in the same household, interact, and contribute to and maintain a culture in their respective roles. 1 The family is the smallest unit in society; it consists of a father, a mother, and a child. Each of these individuals contributes significantly to the growth and development of the child's nature and characteristics; consequently, they have functions and roles that must be fulfilled. According to Friedman, there are five functions: affective function, socialization function, reproductive function, economic function, and health maintenance function. 1 The problem of family process dysfunction is generally defined as a family that fails to perform roles and functions in the family, it can be interpreted that there is an opposition between individuals in the family which causes interpersonal relationships in the family to become disharmonious. In nursing, family process dysfunction is a nursing diagnosis in the North America Nursing Diagnosis Association (NANDA-I) 2018-2020 which has a definition of changes in relationships and or functions in the family. Family process dysfunction has characteristic boundaries that are divided into three categories, namely behavior, feelings, and relationships. Characteristic limitations in the feeling category include the following, presence of anxiety, hostility, confusion between love and pity, depression, distress, frustration, low selfesteem, emotional isolation, failure, loss of identity, emotional control by others, hopelessness, vulnerability, loneliness, fear, tension, helplessness, dissatisfaction, confusion, anger, suppressed emotions, holding grudges, feeling different from other people, feeling ashamed, feeling worthless, feeling unloved, mood swings, abandonment, rejection, feelings incomprehension, guilt, shame, feelings of unhappiness, hurt, responsibility for alcoholic behavior, insecurity, distrust. 2 The family dysfunction characteristic can lead to self-neglect in teenagers especially in street children. The problem of self-neglect is a constellation of culturally formed behavior that involves one or more self-care activities when there is a failure to maintain socially accepted standards of health and well-being, 2 and based on the characteristics of self-neglect according to NANDA namely hygiene inadequate environment, inadequate

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for economic reasons have a higher prevalence of symptoms of anxiety and depression due to physical and psychological violence experienced within their own families, adoptive families, or in rehabilitation centers. 11 Before becoming street children, they are victims of poverty, conflict, or ineffective family function which then experience physical or mental health problems. 5 One of the reasons why children choose to be homeless is due to the family dimension that does not work according to its function.
The children choose to leave their homes and be homeless for three main reasons: poverty, abuse, and family disorganization. 12 From a nursing point of view several nursing problems may arise in street children in the Special Region of Yogyakarta according to the NANDA-I Nursing Diagnosis as follows: 1) self-care deficit, 2) self-neglect, 3) ineffective sexual patterns, 4) ineffective parenting patterns, 5) ineffective coping, 6) dysfunction of family processes. From the background above, it is important for mental health and community nursing to help street children with self-neglect problems. This study was aimed to describe the correlation between dysfunctional family processes and selfneglect of street children in the Special Region of Yogyakarta.

METHODS
This research was quantitative correlation research with a total population are 120 street children in Yogyakarta, and the sample was 90 respondents who were taken by accidental sampling technique. The inclusion criteria of this study were: 1) street children who live in the Special Region of Yogyakarta, 2) willing to fill in the informed consent form, 3) both of boys or girls, 4) in adolescent age or 10-21 years old, 5) not marriage yet. The exclusion criteria were: 1) street children who were not present for data collection, 2) refused to participate. This research was used two instruments: 1) Family dysfunction questioner which was developed from the characteristic limitation of nursing diagnosis from NANDA-I 2018-2020, 2) Self-neglect questioner based on limitation characteristic of NANDA-I nursing diagnosis. The validity test was conducted with 30 street children as a respondent who was not included in the research analysis. The validity test score from the family dysfunctional questioner is 0.361 and the reliability test conduct by Cronbach's Alpha with the score is 0.735. For the self-neglect questioner, the validity score is 0.361 and the reliability test was 0.698. The statistical test in this study uses the Pearson correlation test. This research had undergone ethical clearance with letter number No. 1262/KEP-UNISA/ VII/2019.

RESULT
The respondent characteristics (Table  1) showed that most of the respondents are male (58%), most of the respondents are 10-15 years old (57%). Most of the respondents were originally from Yogyakarta (30%) and had the highest education was in Junior High School (36%). Most of the respondents are being street child almost 2 years. The birth orders are a first child (48%). The dysfunction of the family process has a mean score of 109, and the self-neglect variable shows that the means score was 28.33 (Table 2).
There is a significant correlation between the dysfunction of the family process and the self-neglect among street children in the Special Region of Yogyakarta. The p-value showed 0.000 (p<0.05), which means that the hypothesis was accepted. The r-score or the correlation coefficient is 0.659 which means that they have a strong correlation between a variable and on the positive line.

DISCUSSION
The statistical test in Table 1 showed that most of the respondents were male (58%). Consistent with the result, the proportion of street children in most developing countries such as Indonesia, 13 China, 9 and Kenya, 14 there are more male than female. Street boys are known to be in more trouble and prefer to live with their friends. 15 We can conclude that the number of male street children is more than female because the male often gets physical abuse and prefer to live with their friends.
Based on the age, most of the respondents are 10-15 years old. This result is in line with research which shows personal hygiene, and not complying with healthy activities. 2 The comorbidity of selfneglect are alcohol, drug addiction, poor physical health, self-harm, depression, homelessness, and abuse in women. 3 Selfneglect can be concluded as a problem caused by a physical health problem, drug, and alcohol addiction, homelessness, inadequate personal hygiene, inadequate environment hygiene, mental health problem and it can occur in both men and women of street children.
Street children are girls or boys who live and work on the streets, or in inappropriate places (under bridges, vacant land, etc.) without functional family support and inadequate supervision. 4 Street children are individuals or groups of teenagers who spend their time on the streets, living in any place, children in shelters, children living in orphanages, outcasts, refugees or immigrants, young people with single parents, and individuals who have lost their homestay because his whole family has no place to live. 5 According to Child Protection Law no. 35 of 2014, street children are defined as children who spend most of their time on the streets to carry out daily life activities. 6 Street children is still a big concern in the world, and the United Nations (UN) concern about children is evidence of the increasing worldwide awareness of the condition of street children. 7 The number of street children globally is difficult to determine with accuracy because there are several accompanying challenges, including the tendency of street children to move, they do not want to be found and do not trust the authorities, as well as the definition of street children which varies from country to country so that there is no standard method to calculate them. 8 10 A large number of street children in Indonesia and the world causes several problems. Children who are homeless father, and abandonment by the father. 12 The other research said that full-time street children reported having less support from their families compared with non-street children or part-time street children. 19 Table 2 shows that the high score of family dysfunction in street children who are included in adolescent age. Related to the previous study, family dysfunction has a positive relation with anxiety and depression in adolescents. 18 Family dysfunction during childhood also affects future worsened sleep quality. 20 We can conclude that the high score of family dysfunction during childhood influences mental health such as anxiety and depression and bad sleep quality.
Children with bad sleep quality may choose to live outside the house. The children have a reason to leave their home and their family to be a street-children. The other factor that triggers to become of street children is domestic violence, identity crisis, being born from sex workers, children abuse, poor parenting, and poverty. 21 Socioeconomic status such as parental education level, parental occupation, and family economic status are the causes of anxiety in the adolescents that were significantly associated with family dysfunction. 22 We can conclude that the children who have domestic violence, poor parenting, poverty, and socioeconomic status are easier to get anxiety which is significantly related to family dysfunction.
The mean score of respondents shows that there is a strong dysfunction of the family process. The family has a role and function that must be fulfilled, such as affective function, socialization function, reproductive function, economic function, and health maintenance function. 1 It means that if the five functions are fulfilled, it is unlikely that the family will experience dysfunction. Street children decide to work and be homeless because their needs are not fulfilled, for example, because of economic factors so they are forced to help parents work or the lack of love from their parents.
The economic factor that is causing the family dysfunction is also one of the reasons for children to live in a street. This result is in line with the research that states the economic factor is the dominant factor  that the number of respondents of street children is at most 10-13 years old. 16 The age of 10-15 years is the early-stage development for teenagers, who have a lot of desire to explore. Age is also correlated with how they decide on their problem. 17 The way of making decisions and thinking is also influenced by the last education of the street children. The demographic result shows that most of the respondents only passed junior high school. Related to this research most of the street children did not school or reported having level lower education less than third grade. 12 Junior high school students are a vulnerable population to experiencing anxiety and depression during this transitional period. 18 Based on the period, most of the children are more than two years become street children. Consistent with the result that half of the street-connected children and youth had been on the street for more than two years. 16 Table 2 shows that the dysfunction of the family process among street children was high. The high number of family dysfunction is related to family disorganization. The primary reason for the children being a street children is the disorganization of the family such as parental remarriage, polygamy by the

ORIGINAL ARTICLE
for children to live in street for helping the family economy. 23 The economic factor affects the availability of a permanent residence to live where it will affect the self-neglect of the child. Table 2 also shows that the mean score of self-neglect in street children is quite strong. It is shown that most of the respondent has a problem fulfilling their daily need and does not have permanent residence. Self-neglect is a constellation of cultural behavior that involves one or more self-care activities when there is a failure to maintain socially accepted standards of health and well-being. 2 Several clients who have a self-neglect case are the clients who live in conditions of extreme disrepair with collapsed buildings, broken roofs, ceilings, broken walls, or windows. 24 The conclusion that can be drawn is that the children who live in the street are at a high risk of self-neglect.
The children living on the street without their families are a vulnerable population and they need to care. In Yogyakarta, many street children came from other district namely: Sleman, Bantul, Gunug Kidul, Kulon Progo and Special region of Yogyakarta or outside town of Yogyakarta. The street children come from various family backgrounds and socioeconomic conditions. The study findings are an important reference for nurses especially for community nurses and mental health nurses, social workers, healthcare professionals, and community organizations to make policies and develop an intervention for street children as a vulnerable population.
The correlation between self-neglect and family dysfunction in street children is significant. Self-neglect and family dysfunction in street children have a strong correlation. Children who are born in families with dysfunctional processes are susceptible to mental disorders such as anxiety, depression, and self-esteem disturbance. 18 Depression is identified as a predictor of self-neglect in the older adult. 25 In our conclusion the street children who are from a families with dysfunction process more at risk of developing mental disorders that led to self-neglect.
Family dysfunction has a strong correlation with self-abandonment. Dysfunction of the family process could be linked with individual differences in psychopathology (anxiety and depression) adolescent feeling about themself (self-esteem) and their relationship (loneliness). 18 Anxiety and depression could affect people in fulfilling the nutrition, self-care (bathing, dressing, toileting) as several signs of self-neglect. Although, in some cases of self-neglect is associated with family history and lifestyle. 24 We can conclude that the one of family dysfunction to fulfill the daily needs such as self-care could be implied to self-neglect in a child.
Connected to the function of the family which are reproductive function, affective function, economic function, social function, and health maintenance function. 1 the self-neglect in street children might be doing not got one or more than one of the family functions. We can see on the result that most of the children are experienced to be street children for more than two years. This data is one of the pieces of evidence that street children lose some family functions for two years. Therefore, the self-neglect in street children is significantly correlated with the dysfunction of the family process.
The dysfunction of family process and self-neglect also emerge as nursing diagnose in street children when the characteristic limits according to NANDA-I nursing diagnose are met. Based on NANDA nursing, the characteristic limitation of the dysfunctional family process divides into three categorize that are behavior, affective, and correlation. 2 Characteristic limitations of affective are anxiety, hostility, confusion between love and confusion, depressive, distress, frustration, low self-esteem, emotion isolation, failure, lack of identity, despair, vulnerability, loneliness, scary, shame, etc. 2 The characteristic limitation of self-neglect is inadequate environmental hygiene, inadequate personal hygiene, do not want to do a healthy activity. The current study finds a significant association between dysfunction of family process and selfneglect on street children.

CONCLUSION
The street children in Yogyakarta have several characteristics namely: most of them are male, between 10-15 years old, got their school until senior high school, the highest number is from out of Special Region of Yogyakarta, most of them become a street child for two years and they are the first child. The dysfunction of the family process and self-neglect among street children have a significant correlation with positive and strong correlation.