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Abstract
Background Children in street situations (those who live or work on the street) are known to face barriers in accessing healthcare.
Methods The study combined a remote survey with 33 adult non-governmental organisation (NGO) staff members, in-depth interviews with staff members of 11 NGOs and 4 formerly street-connected adult young leaders and a questionnaire with 30 street-connected children from 15 countries participating in the Street Child World Cup event in Qatar in 2022. Data were analysed using thematic analysis.
Results The participating children have strong connections with supportive organisations and do tend to seek adult assistance when they are ill or injured, refuting the assertion of adult participants and the literature that children in street situations only seek healthcare in emergencies. Some barriers that children in street situations face when seeking healthcare are likely shared by other disadvantaged groups, including the cost of care, long waiting times, the quality of public healthcare and discrimination based on socioeconomic status. Children in street situations may face further discrimination based on assumptions about their lives, their appearance or hygiene levels. Identity documents are highlighted in the literature as a major barrier but seemed less important to the participants. Both adult and child participants emphasised the need for an accompanying adult to find appropriate services and be treated.
Conclusions This study highlights the important work of organisations supporting street-connected children to access healthcare both during and after their time working or living on the street. It concludes that while some of the barriers to accessing healthcare that children in street situations face are not specific to this group, the absence of an adult caregiver differentiates many street-connected children from other disadvantaged groups. This also signals differences among children in street situations, with those with connections to family or organisations having more support.
- Adolescent Health
- Qualitative research
- Health services research
Data availability statement
No data are available. Interview transcripts are not shared because some may allow participants to be identified; and because data sharing was not included in the consent process.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Children in street situations (those who live or work on the street) are known to face a number of barriers in accessing healthcare, including cost, discrimination, long waiting times and a distrust of care providers.
WHAT THIS STUDY ADDS
The study highlights the role of supportive adults—non-governmental organisation workers or family members—in facilitating children in street situations’ access to healthcare.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The study brings implications for policy-makers by drawing attention to the need to improve the quality of free or low-cost public health systems and to support the organisations that assist children in street situations. It suggests directions for future research looking at the issue of access to healthcare in particular contexts.
Introduction
Around the world, children in street situations—those ‘who depend on the streets to live and/or work’ or ‘who have formed strong connections with public spaces and for whom the street plays a vital role in their everyday lives and identities’1—face a range of barriers limiting their access to healthcare.2
The existing literature documents the health risks experienced by children who regularly spend time on the street. Issues of particular concern include: nutrition and growth,2 3 parasitic and infectious diseases (whether airborne, waterborne or sexually transmitted),2–4 violence, including sexual and gender-based violence,2 4–6 as well as accidental injury,3 7 sexual and reproductive health issues, pregnancy and (often unsafe) abortion,2 4 8–10 mental health concerns2 11 and substance use disorder.3 12–14 Some street-connected children have been trafficked into situations of sexual exploitation or forced labour.15 16 Lockdowns in the first year of the COVID-19 pandemic exacerbated economic and nutritional challenges for many children in street situations by removing or significantly disrupting their means to gain money and food.17 Studies of care-seeking and coping behaviours of street-connected children draw attention to a tendency to self-medicate instead of, or before, seeking care.2 18 Some turn to unlicenced or informal sources of medication, or faith healers,18 19 while others rely on friends,10 12 20 or on non-governmental organisations (NGOs) and drop-in centres.7 12 A systematic review summarises the barriers preventing children in street situations from readily accessing healthcare as ‘cost, minority status, stigmatisation by providers, distrust in quality of care and difficulty finding time to seek care because of lost earnings’.2 Available services may be inappropriate for the specific needs of children in street situations,21 22 or this group of children may lack awareness of services or be ill-equipped to make appropriate decisions about seeking care.21 There is limited evidence of the perspectives of street-connected children themselves on access to healthcare.
The present study adds to this literature by collecting the perspectives of street-connected children participating in the Street Child World Cup (SCWC) and the experienced adults who support them from within NGOs from various countries with regard to access to healthcare. While the sample is small and specific, the results emphasise the role of these NGOs and other supportive adults, in facilitating access to healthcare.
The SCWC, an international sports event for children in street situations, organised by UK-based NGO Street Child United (SCU) to raise vital awareness and change how these young people are negatively seen and treated to reach their fullest potential. SCU supports projects worldwide that work directly with children in street situations, invites them to participate in the event and supports their projects and programmes in their country. The sporting events create an international platform to report on broader issues affecting street-connected children, including access to education, gender equality, protection from violence and birth registration. SCWC has previously taken place in South Africa (2010), Brazil (2014), Russia (2018) and Qatar (2022), for football-based events, and in the UK (2019) and India (2023) for cricket. Many of the participating organisations at the SCWC are also members of the Consortium for Street Children (CSC) network. With a network of 200 organisations across 111 countries, CSC has been a catalyst for change in the sector for three decades, working worldwide to ensure the respect, promotion and protection of street children’s rights and ensuring they can access the services they need to thrive and keep them safe from harm. All authors currently work or have previously worked for one of these organisations, giving them an awareness of some of the main issues raised by those who work directly with street-connected children, as well as the gaps in evidence.
Methods
Methods
This study can be considered exploratory in that it identifies initial findings for further research. Following literature review, an online survey for organisations working with children in street situations was developed based on themes present in the literature (online supplemental material 1). Analysis of the survey data allowed for further refinement of key themes, which informed interview guides for children and adults participating in the SCWC organised by SCU and held in Doha, Qatar, in October 2022.
Supplemental material
Interviews were conducted with children and adult team leaders participating in the SCWC. Interviews were conducted by the lead researcher and several SCWC volunteers, who received training. Translation was provided by adult team leaders where needed. The circumstances of the interviews, being conducted between organised activities, meant that not all children were able to be asked all questions in the structured interview protocol (online supplemental material 2). Adults’ interviews used a semistructured guide similar to the survey protocol but allowing for additional topics raised by participants to be explored (online supplemental material 3). Interviews were transcribed and combined with the initial survey data. The combined data set was analysed using NVivo, with a combination of inductive and deductive thematic coding, and Excel. The results were discussed with organisations in the CSC network at a webinar in November 2022, providing a form of member checking to confirm the trustworthiness of the findings.
Sample
Sampling
Both adult and child participants were reached using convenience sampling, taking advantage of the opportunity of the SCWC to bring a group of children and organisations together in one location. The organisations taking part in SCWC are selected by SCU 2 years before each event, based on the strength of their applications and project visits. The participating organisations then select children from among those they have existing relationships with, based on guidance issued by SCU. All children were in the age range of 14–17 years at the time of the event (while this age range could be referred to as ‘adolescents’, we use the term ‘children’ in line with the legal definition enshrined in the UN Convention on the Rights of the Child which describes children as under 18 years of age23). Sporting ability is not intended to be the central consideration. Although sport is at the core of the event, SCWC events also feature an arts and advocacy programme, and NGOs are encouraged to select participants who would benefit from participation in such activities, who may be able to speak on behalf of their peers, and to serve as a role model after the event.
Child participants
The 30 child participants were aged 14–17 years and included 16 members of boys’ teams and 14 members of girls’ teams playing in the SCWC in Qatar in November 2022, representing 15 countries in Africa, Asia and South America. The child participants were selected by the team leaders, but were free to decline to participate in which case another child was chosen. The young people share a history of being street connected, but beyond this, their experiences and circumstances are unique to the individual.
There is diversity in the children’s current situations. Eight children reported that they currently work, coming from the Philippines, Uganda, Indonesia and Egypt. They reported doing odd jobs in the community (two), coaching the football team, acting as a young leader in a foundation, singing in the street, taking photos and helping parents sell meals. One did not specify which type of work.
Their exact relationship with the SCWC organisations varies: 10 slept in NGO-provided accommodation such as a hostel or children’s home, 19 slept in the family home and one reported moving between these locations, but it seems from interviews that this is a more common practice. Those who do not live with the NGOs receive regular support, though the approach taken by the different organisations varies. Due to this strong relationship with supportive NGOs and the opportunities this brings, the children participating in SCWC cannot be considered as representative of all street-connected children. It is likely that their situation is less precarious than many of their peers.
Adult participants
In total, 33 adult NGO workers responded to the initial remote survey, comprising staff from 23 organisations participating in the SCWC and a further nine members of CSC’s network. Five responses were excluded on the basis that the organisations do not work directly with children in street situations, leaving 28 survey responses from 27 organisations in 20 countries in Asia, Africa and the Americas.
To gather more in-depth qualitative data, adults from 11 of the organisations participating in the SCWC were interviewed using a semistructured interview protocol based on the online survey, allowing the focus of discussion to be led by interviewees. Four young leaders—adults (all over 18 years old) who formerly participated in the SCWC as children and now attend as advocates—were interviewed in person with the same protocol.
Results
The findings are organised in three sections: illnesses and injuries, summarising data related to the health concerns faced by children in street situations; care-seeking and coping behaviours, covering how children in street situations respond to illness or injury; and barriers to accessing healthcare, covering the main obstacles that prevent children in street situations from accessing adequate healthcare.
Illnesses and injuries
Children were asked to think of the last time that they were ill or injured, or, if they could not remember the last time, any other time. Children spoke of 38 instances of being ill/feeling unwell (21) or injured (17) (some spoke of more than one incident during their interview). Injuries and illnesses varied in their severity. Injuries ranged from bruised knees to a dislocated kneecap, a concussion after falling down stairs, and a finger recently amputated while the child used his family’s farming machinery. Reported illnesses ranged from minor colds and headaches to typhoid and stomach cancer. In total, 13 out of the 19 asked were described their condition as serious or an emergency.
The remote survey of adults identified various forms of violence to which children in street situations are commonly subjected2 4 5 as a major concern, along with sexual and reproductive health, which may in part be related due to experiences of sexual violence and sexual exploitation.2 6 These categories were each identified by 23 of the 28 survey respondents. Substance use/addiction was identified as a major concern by 20 and mental health by 19 remote survey respondents. The qualitative interview data from adults revealed menstrual hygiene and reproductive health, and mental health, to be areas of particular concern.
Care-seeking and coping behaviours
Disclosing illness or injury to adults
All children were asked if they told anyone about their symptoms when they first became ill or injured. Who they chose to disclose to reflects the different circumstances in which the children currently live. In total, 10 out of 28 told at least 1 parent, while another 10 told an adult associated with the NGO or their football coach. Four told a friend, while one child told their sibling and one was helped by a stranger.
Four of the children did not tell anyone about their illness or injury. They felt that their symptoms were too minor to share, or hoped the condition would improve by itself:
No I didn't tell anyone - such things, I must say we are used to. First thing, when you feel your stomach is paining, all you do is try and go and pee, you don't take it serious, because you are used to it, you feel the pain but you are like, let me hold on, I'll be fine. Because even it’s so hard to get access to services so you just sit down and let things go the way God has planned. (Boy, Uganda, 17)
Seeking healthcare
Adult NGO workers attest that children in street situations typically only seek healthcare in emergencies. This is not necessarily different from others of similar economic status in the same communities who are not street connected:
Kids in street situations are [facing] the same kinds of problems children of similar economic status face too. Healthcare is incredibly expensive and regular preventative medicine is unaffordable. Unless something is life and death, there is no wish to go to the hospital. (Fairplay For All Foundation, Philippines)
In the sample of children attending SCWC, all but three of the children recounted seeking attention from a healthcare professional (including visiting doctor’s surgeries, hospitals and clinics), either for their most recent health concern or a previous health concern. One additional child (Boy, Pakistan, 16) referred to his visit to a traditional ‘bones and joint expert’ who, his Team Leader confirmed, is not a formally qualified medical expert. Most of those who visited clinics, hospitals or doctors mentioned the seriousness of their illness or injury as a reason to seek healthcare, while encouragement from adults was also raised:
I knew I wasn't feeling so well, I knew it was more serious than other times, so I thought that if I go to the hospital I would be feeling better (Girl, Colombia, 16)
I decided to go to the doctor because… I saw that I cannot even help myself, and even if I did not want to tell anyone or even go to the doctor, I will just die in the street, no one will just help me. But then, when that man [a stranger] came and offered that he will take me to the doctor, I just said, no matter what comes of it, I'll just go to the doctor. (Girl, Zimbabwe, 15)
Likewise, those who did not seek medical attention often attributed this to the minor nature of their health concern, except for one who stated “in my town, there are no hospitals” (Girl, Colombia, 16), and another putting their decision down to cost. A 17-year-old boy from Uganda was the only child participant who could not remember any time they had been seen by a doctor. Asked what they would advise an ill or injured friend to do, 14 of 27 children asked included advising them to seek medical attention from a clinic, doctor or hospital, while 7 would advise them to tell an adult.
The discrepancy between children’s reports and adults’ understandings of the situation may be partially explained by the relationship that children in the sample have with NGOs:
For some who are connected to the organisations, they have access to hospitals because every, every month, the organisations, pay for their services. But for those who are not connected or engaged with an organisation, they have nothing to do. I think if it’s a wound they will stay with it until it’s… get worse or maybe luckily it gets dried. (Male Young Leader, Tanzania)
Barriers to accessing healthcare
Cost
Cost was the barrier most often selected by NGO representatives completing the online survey (20 of 28 responses). Even where national health systems allow a child to see a doctor free of charge, in some contexts there are additional charges for treatment:
They don't bother going to clinics if they don't have money as they know that they can't afford medicine or tests (even if they do get a free consultation). (Bahay Tuluyan Foundation Inc., Philippines)
Even in government hospital or public clinic they have to pay cost for X-rays, scans, bandages, specialised medicine, besides tips for stretcher service etc. (Karunalaya Social Service Society, India)
Despite the focus among adult respondents on cost, as mentioned above, only one child referred to cost as a reason they did not seek medical care when ill or injured. Among those who did not have to pay, either their treatment was free due to the public healthcare system in their country or their treatment was covered by the organisation or another adult.
However, cost arose in children’s interviews as a factor that has put them off from accessing healthcare in the past, or which would be a barrier to others in similar situations:
Basically, comforting [a friend if they were ill] would be the best option, because there is no way we can advise them to go to the hospital unless they have something in their pockets. Like my [teammate] said, accessing medication is hard, really hard, and consultation too also goes at a fee, so sometimes it’s all about praying for the better, comforting them and as well as hoping on prayers, because that’s the life. (Boy, Uganda, 17)
Health insurance to reduce or remove the cost of healthcare was raised by four children. One child (girl, 16, Peru) specified that she was covered by her parent’s health insurance. Because of the different health systems in place, insurance had varying levels of relevance across different contexts. For example, all four participants from Tanzania (two boys, a Young Leader, and the Team Leader) talked extensively about insurance, explaining the importance and limitations of the system:
Every single card contains, or can serve up to six children. So, with that card, the organisation pay every month for those six children, it doesn't matter if they have received a service or if they haven't. So that has been very helpful for these young people, especially in youth groups, because we form groups and so it’s easy for them to understand where to get the service or health service or where to get the tablets if they need to, so that has been helpful. (Young Leader, Tanzania)
Those [Community Health Fund] cards they’re like community cards where you just go to the government hospitals and sometimes it’s not that easy to be treated, but at times you just get the services but not other services. For example, when someone has a serious injury, and it costs lots of money, that card can’t support you very well. So basically it’s the card that supports these small small issues but not big issues. (Team Leader, Tanzania)
Requirement to show identity documents
In total, 11 of the remote survey respondents identified the need for legal identity documents as a barrier:
Except for emergencies, they need ID to access medical consultation (Gurises Unidos, Uruguay)
To access health services ID is being asked. For free medical insurance by government children need to have ID proof (Karunalaya Social Service Society, India)
The children’s data support the finding that ID is not a concern in most situations: of those asked, less than a third (8 of 26 asked) remember being asked for any form of ID.
However, the situation is more nuanced. Even where ID is officially required, it may not be requested in practice, especially in emergencies, or there may be ways to get around the requirement.
It would not be entirely required in an emergency scenario. Again, the primary issue for a hospital is ensuring the person got paid. If they had a guarantor, they would treat a patient without ID documents, provided they knew the bill would be settled. (Fairplay For All Foundation, Philippines)
NGOs can facilitate children obtaining birth certificates or other identity documents, or can form a relationship with medical services that enables children to access them without documents. Four children mentioned belonging to the organisation as a reason for not requiring ID, while another explained the doctor already knew him.
They didn’t ask for anything because [the organisation staff] are the ones with the IDs (Boy, 16, Tanzania)
Facilitating the process of obtaining identity documents for street-connected children was also referenced as a recommendation for government:
Because the children who live in the streets sometimes don't have any identity, like the family card or birth certificates, it would make them more difficult to get the access to the health service, so that’s why there are some people that have to help the street children to get the identity card, if they get the identity card they can get health insurance from the government then they can go easily to the public health service. (Girl, Indonesia, 16)
Travel and waiting times
Travel and waiting times are important for children surviving on daily earnings as they lose the ability to work while seeking care. ‘Long waiting times’ was selected as a main barrier by 17 of the 28 respondents in the initial survey. Once at the doctor or healthcare provider, 6 of the 23 children asked reported that they were seen immediately or within a few minutes. Most commonly, children reported waiting between 10 min and 1 hour (10 out of 23). Seven waited more than 2 hours to be seen, including one who “arrived at six or seven in the morning and they helped me when it was around 12” (Girl, Peru, 17).
Waiting times, however, affect most or all people using the services, rather than specifically street-connected children:
This really depends on location and availability of staff. Children are not given any priority, it is normally first come first serve basis. Public health facilities have long waiting times and people can arrive as early as six am to join queues. (Isa Wali Empowerment Initiative, Nigeria)
Lack of awareness
Survey data suggested that children in street situations often lack awareness of health services that are available to them (19 of 28 survey respondents indicated this as a barrier), as well as awareness of how to look after themselves. This perception was supported by adults’ qualitative responses:
In general, most street-connected children don’t know where they can go as hospital because… we do have, what is very sad, we do have some children that have died when they are on the street because they do not know if they can go to see a doctor so go to black market (Team Leader, Burundi)
However, even if free health care is available in some cases (e.g. some government health centres, NGO health care services, etc.), but most of the children do not know about it. (Survey respondent, Bangladesh)
The responses of the SCWC sample may not reflect the situation of those children currently living or working on the street without NGO support. Children who sought medical attention were asked how they knew where to go, with responses including direction from the NGO or parents, visiting the closest government facility or having no other option in their locality.
Lack of accompanying adult
Another factor that emerged strongly in adults’ data was the effect of the presence or lack thereof of an adult accompanying a child when they seek medical care. There was a strong feeling that children trying to access healthcare without an adult will “not be taken seriously” (Team Leader, Uganda), and many felt they would not be treated at all:
While on their own in the streets, they cannot be attended to in the hospital without an adult. (Glad’s House Kenya, Kenya)
Children who are living without adult care are differentiated from those who live either with parents or with an NGO, with the latter category accounting for all the children in our sample.
Kids who come from institutions who are connected with the streets but tend to have more support because they have adults who can advocate, take them to the doctors. If you look at the kids that don’t stay with them [the organisations] […] those aged 15-18 will be treated as a minor and not taken seriously, may not be in position to talk to doctors. Most will not go to hospital because they will not be attended to. (Team Leader, Uganda)
If a street child is sick and in the streets, the child will have to find for himself, as opposed to a disadvantaged family… there will be someone to take a sick child to a nearby clinic or organisation (Team Leader, Nepal)
This both demonstrates the differences among children in street situations, some of whom continue to live or maintain a link with their families, or have built a relationship with a supportive organisation, and differentiates those who are in street situations and separated from their families from those who are in similar economic circumstances but who have not built a connection to the street.
Of the 25 children in the SCWC sample who sought healthcare, 14 were accompanied by a parent or another adult relative, while 8 were accompanied by someone connected to an NGO. One child goes (regularly) with either a parent or NGO staff, while two went with friends. No child stated that they went alone.
Discrimination
In total, 19 of 28 survey respondents identified real or perceived stigma and discrimination as a barrier. Yet when adult participants felt there was discrimination, there was a lack of consensus over whether this discrimination is based on children’s street-connected status, or on their socioeconomic status which is shared with other disadvantaged people. Some felt that children in street situations would be indistinguishable from others, and therefore would not face an increased level of discrimination:
When arriving at the hospital, doctors, nurses, or security guards do not know the individual background of the person. They only know the person looks poor and looks like they cannot pay. The stigma for lower income people is quite similar in that respect. Hospitals largely only care about ensuring they get paid. (Fairplay For All Foundation, Philippines)
However, others suggested that the appearance, hygiene levels or behaviours of children in street situations leads to stigmatisation and discrimination:
Street children care less for their health, and [are] hesitant to seek health as they are unwelcome due to their dress and unkempt look (Karunalaya Social Service Society, India)
We had a situation once that a street connected child needed immediate support, so we called the ambulance, but the nurses refused to take him due to his poor hygiene condition. Also, we had other situation where the doctors inside the hospital refused to view the child because he was ''dirty'' (O Pequeno Nazareno, Brazil)
One survey respondent drew attention to stigmatisation based on the health concerns that children in street situations experience:
The discrimination and ill-treatment is worse when the health issue is considered "abnormal" / deviant/bad for their age - such as sexual diseases in young teens, health issues related to terrible hygiene or substance use (Amani Centre for Street Children, Tanzania)
As noted above, the absence of adult accompaniment can also be the cause of discriminatory treatment:
The children who are living and working on the street, they are being discriminated, first of all because unless they can get the service when they have an adult, if it’s a street child who is only a street child, they can just be chased, it’s like they don’t have the right, People can even think ‘this child is a thief, maybe they’ve come to steal from the hospital’, so actually they are being discriminated (Team Leader, Tanzania)
It’s very difficult to be treated without an adult. They must go with someone, if there is no someone, they are not being treated well… for example, because most of them don’t have proper clothes, sometimes being chased out because of how they looked like (Team Leader, Burundi)
As it was recognised by NGO representatives that children do not tend to report discrimination directly, the children in the sample were instead asked about their experiences of healthcare settings, discussed below.
Experiences of healthcare settings
Children who reported having attended a doctor, hospital or clinic were asked about how they felt and were treated during their visit.
Feelings of safety
In total, 17 of the 25 children who went to a healthcare provider reported feeling safe while there, with one additional child feeling partially safe. Reasons for feeling safe were split evenly between having a known adult with them, knowing the staff or the staff being friendly towards them, the hospital being local and because they felt they would be helped at the hospital, for example:
They told me the sickness I had and they told me there’s a medicine I had to take and then I would feel better (Boy, Burundi, 15)
Reasons for feeling unsafe were a lack of privacy in a shared room, a perceived lack of care, staff being unfriendly towards the child or mistreating them because of their lack of legal identity.
I didn't feel really safe because […] they put me in a room with a lot of people, I would prefer that everyone have their private space so that I didn't have to see the suffering of other people, and that made me feel unsafe (Girl, Peru, 16)
Similarly, 17 said they felt they were treated kindly while visiting a doctor, with four giving mixed or uncertain responses:
Some doctor is very kind, she is talking with me - sometimes some doctors behave nicely, some of them ignore (Girl, Bangladesh, 16)
Those who felt they were treated unkindly related this to feeling ignored or having to wait, feeling that the staff were impatient or did not treat them with care, or in one case refusal to treat an emergency injury due to the child being registered in a different hospital.
It seemed like they were angry, like they were just taking it as a case and trying to get through it, they weren't very nice. (Girl, Philippines, 16)
Quality of public healthcare
One finding emerging strongly from the interviews with both children and adults is that the quality of public healthcare—typically all that is available to children in street situations—is lacking in many of the contexts included in the sample, compared with private healthcare that is accessible to those with more money.
The hospital that is near [the child’s home] is not so good, it’s very low quality - so they run some tests on you but they [the team leader interjects: they don't have an x-ray, the test they do is like a throat swab] and they always say that you're fine because they don't have the resources to say what you have (Girl, Colombia, 16)
The hospital in Egypt is not good - except in the private hospitals but it’s very, very expensive, no one can go there. (Boy, Egypt, 17)
Ultimately, despite being able to access healthcare, 11 out of 28 children felt they did not receive the care needed to feel better. In some cases, this was linked to the way that the doctors and other health service staff treated them, with four children (notably, all girls) commenting that staff in public health services specifically are not friendly or kind to them:
In the public health service the doctor is not really friendly, but in the private clinic the doctor is more friendly (Girl, Indonesia, 15)
In others, it was felt that their problem could have been resolved if they were able to access private healthcare:
I was in great pain that time, so the doctor was trying to help me, but he told me that here we cannot have enough treatment for this injury, you need to go to a private - a proper hospital - for your treatment, so I was feeling like 'I wish I could go there' (Boy, Nepal, 17)
Discussion
This study summarises the main barriers preventing children in street situations from accessing healthcare, based on the experiences of children participating in the SCWC who have been in street situations themselves, and the adult NGO workers and young leaders who work with them. Due to the specificity of this sample, further research is needed to test the transferability of these results. In addition to confirming the findings of existing literature on the importance of affordable access, the present study places further emphasis on the need for a child to be accompanied by an adult to access healthcare. This role can be played by a parent or adult family member, but for many of the children in the study it is the staff members of the NGO with which they have formed a longstanding relationship who fill this position. While a requirement to show identity documents and a perception of discrimination were seen as barriers in some contexts, these were not as widely shared, confirming differences between country and regional contexts.
The qualitative nature of the study highlights interconnections between different barriers: where free or low-cost services may alleviate the price of healthcare through national health systems or insurance schemes, for example, these often require registration which in turn requires identity documents such as birth certificates. While the sample size is small, results tentatively suggest that trends exist across the different contexts in which the children live. This does not refute the presence of context-specific factors documented in the existing literature—for example, in Harare, ‘a letter of referral from an NGO or church’ is required to access hospital care, along with a fee of US$5 or US$10,12 while fear of parents’ disapproval of their deciding independently to visit a doctor was another factor identified by children in Pakistan.18
The distinctiveness of the sample in the present study explains discrepancies in some areas (such as health-seeking behaviours) between the adult’s comments which refer to the actions they observe in children they work with who remain in street situations and the comments of SCWC participants which reflect their current circumstances. The same uniqueness may explain some of the discordance between some of these findings and the existing literature. For example, although the literature suggests that children in street situations will often suffer in silence or rely on other children for support,2 7 18 most (20 out of 28) of those in our sample did tell an adult when they first became ill or injured, with an almost even split between those alerting a parent and those telling someone connected with the NGO. Likewise, we cannot draw conclusions about the awareness of existing health services among the wider population of children in street situations from the present study, due to the longstanding connections with NGOs of those included.
Some of the concerns, behaviours and barriers identified here are not necessarily specific to children in street situations but are likely shared by those of similar socioeconomic backgrounds who are not street connected. In terms of health concerns, this is recognised in the existing literature. For example, there is mixed evidence on the effect of street connection on nutrition and growth status, with a lack of consensus over whether those who maintain ties to community off the street fare better than those who live full time on the street.2 Panter-Brick et al find that those children ‘of the street’ in Nepal are doing better than control groups of poor children who are not in street situations, as well as those ‘on the street’—suggesting that moving to the street is a strategy for coping with poverty at home.24 The additional focus on menstrual health and mental health in the qualitative data of the present study also reflects the rise in prominence of these topics on wider agendas related to children’s health in low-income and middle-income countries in recent years.25 26
With regard to healthcare barriers, some of the concerns raised by the children in the present study are not exclusive either to children or to those in street situations, such as the quality of public healthcare, the limitations of insurance schemes and long waiting times. For example, long waiting times affect the willingness and ability of children in street situations to access healthcare as they lose time that they would otherwise be working or trying to collect money.6 18 21 This, however, could be true for everyone dependent on their daily earnings for survival, not only those connected to the street. This is not to say that some issues with public health systems may not be exacerbated by the children’s situations. The literature suggests that stigmatisation and discrimination of children in street situations by healthcare providers—or fear of this disrespect18 27—also prevents this group from accessing care.21 This discrimination can amount to refusal to treat children in street situations.12 Without a control group or a larger sample, we cannot confirm if the lack of kindness experienced by some of the participating children can be explained by their status and the lack of consensus in the adults’ data suggests this may not be clear-cut.
Strengths and limitations
The main limitations of this survey are related to the nature of small-scale qualitative research. Street-connected children are a heterogenous group, with the term intentionally encapsulating a wide range of circumstances when defined as those who live, work or have another strong attachment to the street. The sample in this study is not statistically representative of this group as a whole. While themes could be identified from the participating children’s responses, the sample is small and it should be recognised that the children involved in the SCWC have opportunities that many of their street-connected peers in their countries do not have, due to the level of support those at the SCWC receive from the NGOs who brought them to the event. For the many street-connected children who do not have access to supportive organisations, there are likely to be additional barriers that are not touched on here, as well as barriers that are specific to their context which may be uncovered with future research.
Nevertheless, the distinctiveness of the sample is also the study’s strength: it is rare to have the opportunity to include street-connected children of a wide range of different nationalities in one study, with most studies being specific to one city or locality. The diversity of the group allowed the identification of themes which, while they cannot be assumed to apply in all contexts or to all street-connected children equally, give direction for further research that may delve more deeply into children’s experiences. There has thus far been more focus on street-connected children’s health risks and outcomes, rather than their access to and experiences of healthcare, and the present study points to the need for closer examination of this latter subject in particular contexts.
Conclusion
Street-connected children, like all other children in countries signed up to the UN Convention of the Rights of the Child (UN CRC), have the right to ‘enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health’.23 This study highlights the important work of organisations supporting street-connected children to access healthcare both during and after their time working or living on the street. It found that the street-connected children participating in the SCWC do tend to seek adult assistance when they are ill or injured. While the adult participants confirmed what the literature tells us about the tendency of children in street situations to only seek healthcare in an emergency, this was not the case for this specific group of children who have formed strong connections with supportive organisations. The study suggested that some of the barriers that children in street situations face when it comes to seeking healthcare are not specific to that group, but instead will be shared, to some extent, by everyone in the same context who relies on a daily wage and cannot afford private healthcare: the cost of care, long waiting times, the quality of public healthcare and discrimination based on socioeconomic status fall into this category. On the other hand, children in street situations may face further discrimination based on assumptions about their lives, their appearance or hygiene levels. Whereas the need for identity documents was seen as less of a barrier than expected after review of the literature, the need for an accompanying adult in order to find appropriate services and be treated was emphasised by adult and child participants alike. It may be this factor which both differentiates the group of children in street situations from many other children of similar socioeconomic status and reveals differences between street-connected children based on their connections with family or with supportive organisations. Further research is required to explore the specificities of these dynamics in different country and regional settings, including engagement with street-connected children trying to access different healthcare systems and with children in different circumstances to those participating in the SCWC. The study brings implications for policy-makers by drawing attention to the need to improve the quality of free or low-cost public health systems, to train healthcare workers in relation to the UN CRC and how to communicate effectively with children and to support the organisations that assist children in street situations.
Data availability statement
No data are available. Interview transcripts are not shared because some may allow participants to be identified; and because data sharing was not included in the consent process.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Medical Research Center at the Hamad Medical Corporation (IRB-HMC-2021-011) in Qatar. Participants gave informed consent to participate in the study before taking part. Children were read a simplified assent form in their preferred language, by a known adult. Children’s names were not recorded, ensuring anonymity. Adult participants signed their own consent forms and chose whether their organisation would be anonymised. The team leaders, who were responsible for the children while in Qatar, were present during the children’s interviews, alleviating safeguarding concerns. The adult team leaders were aware of the themes that would be discussed while suggesting children to participate. Interviews were mostly conducted during other SCWC activities. Although the interviewer attempted to find quiet spots around the edges of events, it was not always possible to be out of earshot of bystanders (other SCWC participants or people watching football matches). This may have affected what children chose to divulge. As this was predicted before receiving ethical authorisation, the interview protocol was intentionally designed to avoid pushing children into giving sensitive details—allowing them to lead which story and how much detail they chose to divulge, and not asking about subjects such as violence at all. Conducting interviews in this manner was also necessary to avoid children (either those participating or other team members) being separated from their responsible adult, who would have also been able to provide support if it were ever needed.
Acknowledgments
The authors thank the participants and volunteers of the SCWC; John Wroe and Dr Arun Midha for their comments on earlier drafts; Dr Roberto Bertollini, Sultana Afdhal and Hatoun Saeb for their support for the project. Early findings from the initial stages of this research were presented at the World Innovation Summit for Health 2022.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @shomacleod, @streetchildren
Contributors SLM led the research design, conducted data collection and analysis and wrote up the manuscript and is responsible for the overall content as guarantor. PM and JP conceived the need for the study through their respective organisations, participated in the research design and contributed to interpretation and write-up. All authors read and approved the final manuscript.
Funding Funding for this research was provided by the World Innovation Summit for Health (WISH). The primary author (SLM) was engaged as a consulted by Street Child United and Consortium for Street Children using funds that were part of a £28,500 grant from WISH in 2022. No grant number was provided.
Competing interests None.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Commissioned; externally peer reviewed.
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