Sexual and Reproductive Health Problems and Needs of Street Youths in East Gojjam Zone Administrative Towns, Ethiopia: Exploratory Qualitative Study

Introduction

Sexual and reproductive health (SRH) and well-being are essential if people are to have responsible, safe, and satisfying sexual lives.¹ However it is deprived in the case of street children who have no opportunity to access a sexual and reproductive health service. The United Nations Children’s Fund (UNICEF) has labeled street children as “children in difficult circumstances”, who represent a minority population and have been under represented for too long in health research. The street child population has also been categorized into two overlapping groups: 1) “of-the-street” children, who are children having no contact with family and hardly ever return home and: 2) “on-the-street” children, who often sleep at home but are based on the street during the day.²

The exact number of street children is impossible to quantify, but the figure almost certainly runs to tens of millions across the world. It is likely that the numbers are increasing as the global population grows and as urbanization continues apace.² The growing numbers of street children is one of the most serious urban social problems facing Ethiopia today. In the country as a whole, it has been estimated that as many as one hundred thousand children are engaged to varying degrees in street life activities.³ There were also about 1900 street youths aged 10–24 in Dessie town.⁴

The adolescence period is characterized by immaturity, exploration and experimentation behaviors of adolescents and subjection to peer influences. When viewed from various behavioral, cognitive and developmental perspectives, young people can be labeled as a vulnerable group; because this segment of population is threatened by sexual and reproductive health problems.⁵

A risky sexual behavior is one that increases the likelihood of adverse sexual and reproductive health consequences. These health consequences may include unwanted pregnancy, unsafe abortion, HIV/AIDS and STDs. Examples of such behaviors are: sexual activity under the influence of substances, sexual intercourse with drug users, unprotected sexual intercourse, commercial sex/survival sex/prostitution, and unprotected sex with a same sex (particularly between males) partner.⁶ Children have become the most vulnerable and most prone group to be infected with HIV. This is particularly true of adolescent girls and young women those aged 15–24 – who constitute between 40% and 50% of all new infections.⁷

For street children, environment does not provide protection against such vulnerability. Street children are highly involved in risky sexual behaviors in order to survive. These situations exposed them to sexually transmitted infections (STIs) and HIV/AIDS.⁸ STIs like gonorrhea and including HIV/AIDS among street children have been reported as being very high and some studies showed that it can be higher than that of female sex workers, truck drivers and prisoners.⁹ According to EDHS, 2016 report HIV prevalence in Ethiopia was 0.9 nationally and 1.2 in Amhara region. Overall, 0.2% of young women and men aged 15–24 are HIV-positive.¹⁰ A study conducted in north west Ethiopia indicated that, among sexually active street youths, 24.8% had a history of sexually transmitted infections, 37.5% had unwanted pregnancy, and 40.6% had sexual intercourse with sex workers.¹¹

The Ministry of Health of Ethiopia began working toward a policy to address adolescent reproductive health needs in 1996. It directed the formation of a national adolescent reproductive health steering committee, instituted training on adolescent reproductive health management for health care providers, developed and distributed IEC materials, and conducted and participated in ARH workshops.¹² A new Adolescent and Youth Health Strategy also formulated for the period 2016–2020 to guide programs to mitigate the dual challenge that the country faces from the emerging health threats as well as those from the unfinished agenda of preventable death and infectious diseases among its large adolescent and youth population.¹³ However, street children have been largely ignored in the fight against HIV/AIDS. While some initiatives exist, the nature of street life probably has not allowed effective interventions to be implemented.¹⁴ Little is known about sexual and reproductive health problems of street youths and their need in the study area. In order to improve the reproductive health situation of young street people, awareness of their reproductive health problem and their need is paramount. The aim of this study is to explore reproductive health challenges and needs of street youths in the East Gojjam Zone.

Methods and Materials

Study Area and Period

The study was conducted in administrative towns of the East Gojjam Zone from February to March, 2019. East Gojjam Zone is one of the nine Zones in Amhara region. In this Zone there are four town administrations in which a large number of street youths are densely populated due to increased migration from nearby rural kebele and other socio economic reasons.

Study Design

A descriptive phenomenological study design was conducted.

Source Population

All street youths residing in East Gojjam Zone town administrations.

Study Population

Purposively selected street youths residing in East Gojjam town administrations were our study population.

Sampling Size Determination and Sampling Techniques

Purposively selected street youths and positioned individuals who are residing in East Gojjam Zone town administrations and competent to give adequate information about reproductive health problems of street youths and their needs were included in the study. Eight focused group discussions (FGDs) comprising 8–12 individuals and 8 in-depth interviews were conducted.

Operational Definitions

Street youths:- children who are 15–24 years old, comprising on and off street children. Risky Sexual Practice:- youths who had sex earlier than 18 years of age, or have sex with a non-regular sexual partner, or exchange sex for money, or have more than one sexual partner or use condoms inconsistently

Substance use: utilization of alcoholic drinks, tobacco, chat, hashish, and benzene.

Data Collection Procedure

Data Collection Procedure and Tool

Data were collected using a semi-structured open-ended interview guide. In-depth interviews and focused group discussions were conducted by trained interviewers, facilitators and note takers. The interviews and discussions were held in Amharic language. In order to make the environment easy for participation and discussion participants were sex disaggregated.

The overall data collection process was thoroughly controlled. The full interviews and discussions were tape-recorded and notes were taken during discussions. Focused group discussions were carried out with street youths while the in-depth interviews were conducted on purposively selected district health officials, local administrative officials, Zonal and district level women children youth and social affairs volunteers who were working with street youths and district health officials.

Data collection was continued until saturation of information. For this particular exploratory qualitative study, participants reported their real life experiences and observations.

Data Quality Control

Data collectors and supervisors were trained on the purpose and objective of the study, data collection tools, and interviewing techniques for one day including practical sessions. Data quality was assured by reviewing each interview daily throughout data collection by principal investigators. Data completeness as well as consistency was achieved in data collection, data entry and in the analysis step. Informed verbal consent was obtained and confidentiality was assured in order to get appropriate information.

Ethical Considerations

The proposal was approved by Debre Markos University Research and Community Service Office. The ethical committee approved the participation of those street youths who were below 18 years old. Verbal informed consent was also accepted by the ethical committee. A letter of cooperation was submitted to respective town administrative Labor and Social Affairs offices. All of the study participants were informed about the purpose of the study and oral consent was obtained before participation for data collection and publication of anonymised responses. Respondents were notified that they have the right to refuse or terminate at any point during the interview and discussion.

They were also assured on the confidentiality of information they provided. Participants were assured that they would not face any harm due to their participation in the study.

Data Management and Analysis

Data were transcribed in to English text by replaying the recorded interviews and discussions. Point of idea saturation was the assurance to end the in-depth interview and focus group discussion. Concepts were merged in their thematic areas and a manual thematic content analysis was employed. The results were summarized and presented in narrative forms.

Result

A total of eight focus group discussions comprising 8–12 participants were conducted in four town administrations. The total number of participants were 85 in the age range of 15 to 24 years old. Ten of them were female street youths (Table 1). The discussion was mainly focused on street youths level of awareness towards reproductive health, existing reproductive health problems on this particular group of people, their reproductive health needs or solution recommended to improve their sexual and reproductive health status.

Table 1 Sociodemographic Characteristics of Street Youths, North West Ethiopia, 2019

Eight in-depth interviews were also conducted with different stake holders comprising, Zonal and district level labor and social, women, child and youth affairs, health offices and volunteers who were directly concerned with street children and youths (Table 2).

Table 2 Sociodemographic Characteristics of Participants on in-Depth Interview Related to Street Youths, North West Ethiopia, 2019

Theme One: Existing Sexual and Reproductive Health Problems on Street Youths

Sub Theme 1.1 - Inadequate Sexual and Reproductive Health Information

Most street children who participated in this study did not know anything about sexual and reproductive health. This is also supported by officials working in district health office:

Even though some of them have awareness towards reproductive health, most of them have no information about it. Because they are engaged in this life unintentionally. So, we understand that they have high chance of exposure for reproductive health problems.

District level male official, 48 years old.

Some of them had misconceptions about it such as considering SRH as first aid, prevention of disease and keeping personal hygiene. As indicated in the following statement:

“ … Sexual and reproductive health is the first care given to you when you suffered from an accident … ”

Male discussant, 15 years old.

Only one male and one female street youth had better awareness on SRH as expressed in the following statement:

“I think it is the health care given for mothers who are giving birth … ”

Male street youth, 17 years old.

Sub Theme 1.2 - Sexual and Reproductive Health Safety

Female street youths stated that their safety mainly relied on their male friends.

On my life I didn’t exposed to such problems …. I am starting to live here for a long time … we all females and males supported each other and living together …. if other people come to attack us, they (males) will support us. However, most of the time male street youths said that they are in love with you … and obligate you to sleep along with them without your interest …. That thing (to mean condom) might be burst.

Female street youth, 18 years old.

In this time, when we are on “katera” (working different activities in the night time) or “Jeblo” (selling soft, candy and so on around hotel, cafeteria and on the rod) at night … if somebody come to attack us, even though there is federal police or Keble polices around there and informed to them, they will start to strike us since they perceived as we have contact with theft individuals and coming here to conduct “chebo” (hanging for stealing) and so on … Nobody is protecting us! However, I saw one girl who was faced rape by 12 individuals once on the street; We did not do anything …; we did not get her after that time since she is not our friend … she is working on business (sex for money).

Female street youth, 18 years old.

Some male street children had also a chance to see their friends who were affected by rape.

Males may be raped by males … Street children raped by street children as my observation, I didn’t see street children raped by others … the violence attempted by others is beating.

Male street youth, 17 years old.

Previously it (male homosexual) was present … when they come to here from other place, they call to street children and do what they want; after a while those street children who are affected with this situation disappeared from here.

Male street youth, 20 years old.

In our setting there is no rape. When I was in Addis Ababa, there was one organization what you call Retract Ethiopia … one child who was supported by this organization run away from the institution and then he exposed to rape; at that time … we tried to collect money and send him to his former residence.

Male street youth, 18 years old.

There was one child who was raped in the Hotel. he had some mental health problem, we were giving meal … every one considered as bedlamite and defalcate him … here there is no one think about us they considered us something. Even, on the time of his abuse, the owner of the Hotel connive with the police and gave 200 or 300 birr for that child and discontinue legal proceedings … this indicated as they are not giving value for human beings. They were palliate that situation and leave it. Previously he was polishing shoe but after this situation, he runaway to his former residence and developed severe mental illness.

Male street youth, 18 years old.

Sub Theme 1.3 - Unplanned Pregnancy

The other SRH problem faced by street children was the occurrence of unplanned pregnancy.

I was experience unplanned pregnancy … but not due to rape … it is with love … laughing …. There is one situation occurred on my friend … while they were on the street, they failed on love and gave birth on the street and continue to live there.

Female street youth-21 years old.

Officials who were working in health office also had similar explanation on it.

When we see Street children who are on secondary sexual characteristics stage, they are thinking different perquisite and cajolement to solve their temporary problem, they might have wide probability to enter in to unnecessary sexual intercourse. Due to this reason, they might give birth and face economic problems for child care … it makes difficult even to give psychological treatment for them because, they are engaged in to this situation without prior knowledge about the place where the health care service is available. The other problem is shelter; the problem is becoming different b/n single and those who have children on the street.

Male, district level HIV/AIDS and emergency response officer, 48 years old.

Sub Theme 1.4 - Accusation of Sexually Transmitted Infections

One of the SRH problems of street youths was accusation of STI as indicated in the discussion:

Few street children were exposed to sexually transmitted infections. From us, one of our friend had sexual contact with the one who was working business (commercial sex worker) … he was infected with sexually transmitted infection and treated after a while.

Male street youth, 18 years old.

There is also a probability of acquiring sexually transmitted infections including HIV/AIDS. These multiple problems becomes difficult on the management of their life. … Especially this area is small, highly populated and overcrowded with cars; their (street children) unnecessary relation with these people might lead them to reproductive health problems.

Male district level HIV/AIDS and emergency response officer, 48 years old.

“I was assisting about three street youths who had sexually transmitted infection to get treatment.”

Male volunteer working with street children, 32 years old.

Sub Theme 1.5 - Lack of Recognition on Reproductive Health Burden of Street Youths

The burden of RH problem on street youths was not well known by some of the concerned government bodies who were working on related tasks due to the information gap between different concerned officials as stated below:

It (SRH problem) may be present … they are not freely express their ideas like that of commercial sex workers; even they are not interested to talk with us and getting counseling service. Even though they are not disclosing to us, the problem is known because most of them are drinking alcohol, smoking cigarettes and chewing chat … after a while, they may not know what they are doing

I 6-Female district women, children and youths affairs officer, 28 years old.

Once these children separated from their parents and enter in to difficult precipice, not only these children but also all people in the county are expected to get infections widely.

Since this area is considered as hotspot area, CDC assigned 10 professionals and working some activities however, there is a gap on identifying the number of street children available here; how many of them are changing their life; how many are currently added; where they are living; what services are provided for them and so on. At this time when you told me, what I am thinking is that … for whom we can give this responsibility? How can we evaluate it?

Male, Head of district health office, 50 years old.

Most of the concerned bodies in the zone agreed that the SRH service is not well addressed for street children as stated in the following statement:

We are working on RH on street children however, I don’t think so it is rational. We haven’t doing as expected from us due to different factors like budget, health professionals interest and so on … We have to give training for these (street children) regularly until they are acquiring behavioral change and reached on consensus with us but it needs budget … In addition, even though we have got budget for training, we need to have additional money that can cover their daily income … otherwise, they may not attained us. Due to this reason; we are not expecting as we are doing convincing work on it.

Male, district health office HIV/AIDS and emergency response officer, 48 years old.

Few stakeholders who are working with women, children, youths and social affairs did not consider it as the part of their task and knew anything about the burden of SRH problems on street youths.

I did not do anything related to health … our role is returning street youths to their families … We do not know about SRH … previously we were returning them to their families after awareness creation on substance abuse; however some of them are returned back to the town and become permanent resident.

Female women, children, and youth affairs officer, 24 years old.

To tell the truth, we did not identify deeply whether street youths are facing any health problem or not, using substance or not. Especially they have risks towards reproductive health issues, they are living on the street day and night but we do not have clearly identified information on their level of risk exposure.

Male, district level social affairs representative, 28 years old

Theme Two: Sexual and Reproductive Health Needs of Street Youths

Sub Theme 2.1 - Availability and Accessibility of Reproductive Health Services

Category 2.1.1 - Accessing Reproductive Health Information

Most street youths were interested to get information about sexual and reproductive health issues from concerned bodies especially from health facilities as they stated below:

Even though health workers meeting us, they didn’t ask any thing …. mostly they are working on business women (women who practice sex for money), no body providing information to us. At least, it is better to give us counseling service by them similar to business women. Since we have no any chance to hear news, radio and so on.

Female street youth, 18 years old.

Health centers should give us education about prevention methods … for example, I don’t have any sexual contact till now if I will get some money and want to practice it, I don’t know how the condom will be utilized.

Male street youth −17 years old.

Category 2.1.2 - Availability and Accessibility of Condom

Some of the participants were informed on the availability and accessibility of condoms:

To have sexual contact condom is mandatory … most of the time it is good to be free of charge and available everywhere even though I don’t know who should do it.

Male street youth, 18 years old.

Category 2.1.3 - Special SRH Program for Street Youths

The need of a special program for sexual and reproductive health service provision to street youths was sighted as the following:

The mass activity cannot change their life; some might have a change but most of them may be return to their previous activities. However, there is no any special program running for street children even though there problem is wide. So, specific organization working on them is needed … ”

Male district health office representative, 48 years old.

Sub Theme 2.2 - Peer Support

Some of the street youths also focus on prevention of substance abuse.

Regarding to substance use, we know each other … If I saw one of our friends while he is chewing chat, I have to give advice for him. We have to support each other

Male street youth, 17 years old.

To be free from addiction, he ”street youth” needs to get advice … if he doesn’t hear; we have to tell or apply some …. shocking things.

Male street youth, 15 years old.

Sub Theme 2.3 - Community and Government Support

Some street children also recommend the community to have a favorable attitude towards street youths.

The community also discriminate street children, the perception of your neighboring community on street children is bad and lowest … they don’t know what we have in side rather than our dirty cloth … if someone is street children, he considered as thief, addicted and a scam. That is why they are not looking as their relative and child. If the attitude of the surrounding community was good, street children might not expose to addiction … they become healthy.

Male street youth, 20 years old.

All participants also believed the need for government support towards their socio-economic status and job opportunities.

We have to be out of this life and engage to other work … to change our life, we need others support … The government should support us like other places concerning to our health, education and economy.

Female street youth, 19 years old.

Most participants from different stakeholders also agreed on the need of allocating budget and improving the socio economic status of street children for their behavioral change.

The government should allocate budget for behavioral change on street children. After behavioral change we need to assign them on consistent income generating activities which have no risk of exposure on their former behavior. They need to have initial capital and working place. As an organization, even though there is no budget, we need to work selectively in regular way towards behavioral change without give-up since they are living with complicated problem.

Male district level HIV/AIDS and emergency response officer, 48 years old.

Some of the participants recommended the need to have a rehabilitation center for those who had addiction problems at the district level.

The responsible body for this should be the government … it should collect those who are addicted on this substance and take them to rehabilitation center at district and regional level by providing these substances in small amount along with different recreational things like TV … that can refresh their mind. If you are smoking 15 cigarettes per day you can take 10 then 5, … through time you can stop … it needs time. But you need to have something to see like television, football and other recreational things, if you have this you will shifted to those things which can make you happy. So, the government should do it

Male street youth, 18 years old.

Sub Theme 2.4 - Intersect Oral Collaboration

The need of inter-sectoral collaboration to solve their reproductive health problems was also pointed out by most of officials.

First thing we have to receive our duty in measurable way and incorporate at the lower level of health extension program in order to get these children. Since it might be challenging us after a while, we will share the technical part along with women and social affairs … so, we need to collect expected duty from us … I think we will get change on it. The other thing is, social affairs have its own program which can join these children with their family but we need to see their life skill and how they are meeting with their family

We have monthly meeting organized by Justice, police, social affairs, education, health and Debre Markos University on the issue of beggary, we will connect it (SRH of street youths) with this program … If none governmental organizations working on this task will enter here, the door is open for them and we have to work in collaboration. Concerning our duty, we will strengthen the way how children and youths will get priority on health care service.

Male, head of district health office, 50 years old.

Discussion

Most street youths were not able to understand what sexual and reproductive health meant. Especially those male youth street children who had misconceptions and considered it as management of emergency situations and prevention of communicable diseases. Even those who had relatively better understanding on reproductive health, mainly related it with only that of family planning service utilization by married women.

The main reason might be their educational status since the majority of street youths in this study had no exposure to school or discontinued their study early in the lower grade due to lack of economic support, similar to other studies.^15,16 This might lead them to miss health related information which had been provided in the school.^17,18 The other reason might be the low chance of exposure to different sources of health information due to their unstable living conditions. Even they could not know which services were allowed to them free of charge. The responsible organizations also mainly engaged with creating awareness towards income generating activities than their health status, including their SRH. This is supported by the study conducted in Addis Ababa in which the accessibility of sources of information was the main reason for lacking information towards reproductive health.¹⁹

Most of the participants agreed that sexual violence was one of the problems mainly affecting the SRH of street youths. In this study, even though male street youths safeguard females from perpetrators, female street youths were obliged to have sexual contact with the ones who were living along with them without their interest to maintain their relationship. If female street youths refused to have sexual contact and informed legal bodies, they might not get any support, rather legal bodies might consider both of them as thieves and beat them as they want. The prejudice towards street children might loosen the protection of street children from any harm by legal bodies. This might urge them to rely only on that of male street youths and accept their request since they are frightened by them.²⁰ This is also in line with the study conducted in Addis Ababa, Ethiopia in which those who refused such sexual advances were beaten up and chased away from that particular area of the street.⁸

Rape was considered as one of the most common problems for female street youths in this study. This is also supported by other findings in which the prevalence of sexual abuse on street girls was very high.²¹ In this study, one street youth could be forced to have sexual contact with many individuals at a time. The reason might be due to lack of social support and their living conditions in which many street children slept together in a particular space.^22,23 Few male street youths had also sustained rape by the same sex and developed post traumatic mental disorder. This was practiced either voluntary for exchange of money or due to fear of individuals from their threatening behaviors. This is in line with the study conducted in Addis Ababa.²³ Loosen legal practice also had a great contribution on the existence of sexual abuse on male street children.

In this study some of street girls experienced unintended pregnancies and caring for their child on the street. Some of them also faced abortion and its complication. This might be due to the gap in utilization of different SRH services. In addition to this, their sexual intercourse mostly followed alcohol drinks or substance use that could urge them to have un safe sexual practice which is supported by other findings.^11,24 Acquisition of STI was also another challenge on these street youths. This might be due to their risky sexual behavior similar to other studies.^22,25

Most of the concerned bodies in this study believed that they were not interested to recognize SRH issues of street youths and act accordingly. The main problem, in the HIV/AIDS discourse in Ethiopia appears to be not a lack of knowledge about HIV, but a lack of accountability and willingness among citizens in acting on what they know.²⁶

Most of street youths were interested to get SRH information from concerned bodies especially from health professionals. This might improve their health seeking behavior towards SRH service and their health status. Even their health status is important for the weal fear of the general population. Availability and accessibility of condom was also one of their concern. Even though they would have acquiring good knowledge on SRH, they might not apply what they were knowing due to their economic problem unless its cost is covered by concerned bodies. Accessing reproductive health service is the right of every individual including youths.²⁷ Special SRH program which is suitable for street youths was also needed in this study to avert the impact of HIV/AIDS on the population. According to the study conducted in AA, HIV prevention and impact mitigation programs were not adequately addressed due to lack of targeted interventions and isolation of the street youth from the mainstream community.²³

Street youths also needed their Peer support to have better SRH life. It is important to capitalize on the positive aspect of the peer influence as an opportunity for behavior change communication among street children and youth towards HIV risk reduction behavior.²³

Almost all study participants were agreed on the need of community support towards street youth’s behavioral change since social exclusion was one of their main challenges contributing to their SRH. Street youths were not merely suffering from physical homelessness, but also from psychological homelessness.²⁸ This could cause distress, depression, loneliness and other psychosocial problems which are the driving force for substance use. Community participation is vital at all steps of street children’s programming, including: awareness raising, needs assessment, program development, program implementation, monitoring and evaluation.²⁹

Street youths believed in the need for government support towards their socio-economic status by arranging job opportunities that can change their street life. This was also supported by government officials who were engaged on the issue of street children. This would have a direct and indirect impact on the SRH of street youths. Building assets for youths both financially and mentally is important to integrate them in the community.²⁹ Officials participating in this study recommended that the government and concerned organizations allocated adequate budgets for behavioral change interventions and work selectively in a regular manner until behavioral change exists on this segment of population. The need for a rehabilitation center at district level was also pointed out by some street children to prevent the impact of substance abuse on their SRH. The rehabilitation center helps affected individuals to adopt healthy behaviors.

In this study the intersect oral collaboration was considered as an important strategy to improve the SRH of street children since no single organization can change the program alone. Health sectors also should take their responsibility in a measurable way and share the technical part along with women and social affairs and evaluate the effect of each activity performed on street youths regularly.

Limitation

The unavailability of a full street youth’s data in all districts was one of the challenges to conduct data collection in a timely manner and also limit some of the information that can be explored quantitatively. Some of the participants who were using substances could also not participate actively.

Conclusion and Recommendation

In this study most street youths had no information about SRH and how they could utilize the services provided in the health facilities. Most of them were sexually active and practiced unsafe sexual intercourse which exposed them to different sexually transmitted infections, unplanned pregnancy and abortion. No one was responsible for the SRH of street youths in East Gojjam Zone. Their SRH needs were accessibility of SRH services as well as community, government and peer support and intersect oral collaboration. So, the Ministry of Health should incorporate accessible special SRH services for this particular part of the population. Psychosocial support from the community, creation of job opportunities by investors for street youths, temporary information centers for a place where this group of people were mostly available and a permanent comprehensive youth center are needed.