Risk factors of sexual and reproductive health problems, service utilization, and its challenges among street youths in East Gojjam zone, North West Ethiopia: exploratory qualitative study

Abstract

Background

Children on the streets are still vulnerable to early and unsafe sexual experiences. Having multiple sexual partners and the limited use of condoms were major risk factors for the spread of sexually transmitted diseases among youths in Ethiopia.

Objective

This study aimed to explore the risk factors of sexual and reproductive health problems, service utilization, and challenges among street youths in the East Gojjam Zone.

Method

A phenomenological study design was employed on street youths residing in the East Gojjam Zone. Study participants were purposively recruited from four town administrations in the East Gojjam Zone. The primary study unit was street youths who live in the zone. Eight in-depth interviews and eight focus group discussions were conducted. The data were audio recorded and analyzed using inductive thematic analysis.

Results

In this study, the risk factors that exposed street youths to sexual and reproductive health problems included low perceived susceptibility, lack of awareness of sexual and reproductive health, having multiple sexual partners, exposure to pornographic films, and utilization of alcoholic drinks and substances. Mainly, those street youths who were engaged in transactional sexual relationships were utilizing condoms consistently and had regular HIV screening tests. In addition, few street youths ever utilized maternal and child health services. The unsupportive behavior of health professionals, the absence of exact data, the health system, and lack of specific responsible organization on the sexual and reproductive health of street youths were considered major challenges.

Conclusion and recommendation

Most of the street youths were not utilizing reproductive health services. Limitation on the accessibility of sexual and reproductive health services to this segment of the population was the main contributing factor. So, the health system and policy should take front-line responsibility for the sexual and reproductive health of street youths and consider convenient reproductive health service programs for them.

Introduction

According to the United Nations, about 150 million youths spend most of their time on the streets. This is becoming a global phenomenon, and the majority of these vulnerable individuals live in large cities and urban areas of developing countries [1]. In 2007, the Ministry of Labor and Social Affairs (MoLSA) reported that Ethiopia had 150,000 street-connected children [2]. The daily life of street-connected children in Ethiopia often involves sleeping on the floors of verandas (the open areas of closed shops), along major city streets, or in sewage ditches. Their sleep is frequently interrupted by security forces who round them up and beat them or by rain that makes their sleeping spots wet. They start their days exceptionally early, compelled to vacate their sleeping locations before nearby businesses reopen. Relentlessly searching for food and job opportunities is a typical daily struggle. Late afternoons serve as a respite for those who have secured lunch and a small amount of money, allowing them to play football, pool, gamble, or watch movies at film bets (movie-watching venues). They spend the rest of the day sitting in groups and chatting, often in dirty places [3].

Though youth are considered relatively disease-free by societies, they are at greater risk of various health problems [4]. The highest prevalence of HIV is also seen in the group aged 15–24 years [5]. Children on the streets remain vulnerable to early and unsafe sexual experiences. According to a study conducted in South Sudan, about 20% of street children had experienced sexual intercourse [6]. Living on the street is directly related to exposure to drugs and substances. Street youths report that they use substances to fit in on the street, to cope with street life, sexual abuse, violence, or survival [7]. Being raped or raping others is also a common experience among street children [8]. The most difficult challenge they face is older street children forcing the younger ones to engage in either vaginal or anal sex [9].

Violence and sexual abuse were ubiquitous in the world of street children however, the prevalence of sexual abuse of street girls was even higher [10]. Unintended pregnancy was also another serious problem among street youths [11–13].

The two major risk factors for the spread of sexually transmitted diseases (STDs) among youth in Ethiopia are the practice of having multiple sexual partners and the limited use of condoms [1, 4, 11]. Sexual relationships among street children and with outsiders are widespread. Having multiple sexual partners is a common practice. According to the study conducted in Gondar town, a town in northwest Ethiopia, out of those who were currently sexually active male street children, 40.6% reported that they had sexual intercourse with sex workers in the past 12 months [14]. Among the sexually active respondents, 73.8% had ever used a condom, and 46.1% of these used condoms consistently [6]. Street children also have limited access to health care [12]. Most of the street girls were not even aware of the location of reproductive health centers and how to seek assistance [15]. Of those sexually active street youth, 57.4% had ever used modern contraceptives [4]. More than two-thirds, 70% of those who visit health institutions had reported that they had visited the health institutions for reproductive health problems such as STIs 22(31.4%), for counseling 14(20%), and for family planning 11 (15.7%) [16]. Of those participants who experienced STI symptoms, less than half (46%) of them ever sought medical treatment [17].

In many low-income countries, SRHS (Sexual and reproductive health services) have traditionally been for married and older women. Young unmarried women were not expected to have the SRHS need [9]. Ethiopia has made several international and national commitments that recognize the right to health and entitle all persons, particularly adolescents and youth, to available, accessible, acceptable, and quality health-care facilities and services [18]. Even if health services, including RH services, are accessible and acceptable, not all groups of youths can obtain the services they need [19]. Costly services, unsupportive attitudes of service providers, too much waiting time, inconvenient health institutions, too far health institutions, and fear of confidentiality were reported to be the major obstacles that prevent street youth from visiting health institutions [16, 17]. Many urban centers in the East Gojjam zone have witnessed a rising number of individuals and families living on the streets. Risky sexual behaviors, substance abuse, unwanted pregnancy, and STI are common SRH problems among street youths in the Zone however, they have inadequate information and access to reproductive health services [20]. Therefore, this study aimed to explore risk factors contributing to SRH problems of street youths, their SRH service utilization, and challenges for SRH service utilization in the East Gojjam Zone. It will provide baseline data for researchers and a valuable viewpoint for policymakers to improve the SRH of street youths.

Methods and materials

Study area and period

The study was conducted in the administrative towns of East Gojjam Zone from February to March 2019. East Gojjam Zone is one of the nine Zones in the Amhara region. In this zone, there are four town administrations in which a significant number of street youths reside. However, their exact number was not well known and well registered by the local government due to their mobile nature of living.

Study design

A phenomenological study design was employed. A phenomenological study is a qualitative research approach that explores and understands the meaning of individuals’ lived experiences and how they perceive a particular phenomenon.

Study population

The study population consisted of all male and female street youths residing in the East Gojjam Zone town administrative. Street youths were off the street or on the street and participated in various activities to generate income.

Sampling size determination and sampling techniques

Purposive sampling was employed to select participants based on their street life and the research objectives. District-level officials from the Women, Children, Youth and Social Affairs and a community member who had a strong attachment to street youths were involved in the recruitment of study participants.

The study was included street youths who were purposely selected, along with individuals who had direct or indirect responsibilities related to the sexual and reproductive health (SRH) of young people in the East Gojjam Zone. These participants were deemed competent to provide relevant information about the sexual and reproductive health of street youths.

Operational definitions

Street youths

those who are 15–24 years old, comprising on and off the street.

Risky sexual practice

Youths who had sex earlier than 18 years of age, have sex with a non-regular sexual partner, exchange sex for money, have more than one sexual partner, or use condoms inconsistently.

Substance use

_utilization of alcoholic drinks, tobacco, khat, hashish, and benzene.

Data collection procedure

Data collection procedure and tool

A semi-structured, open-ended interview guide was used for data collection. Trained facilitators, note-takers, and the principal investigator conducted in-depth interviews and focus group discussions. The interviews and discussions were held in the local (Amharic) language. To make the environment easy for participation, participants were sex-disaggregated; a suitable place that was safe, quiet, and comfortable was arranged for data collection, and codes were also given to each participant to keep their confidentiality and dignity. The cost of meals for the participants on the day of data collection was covered since they missed their working time. The full interviews and discussions were tape-recorded, and notes were taken during the discussions. Focused group discussions were conducted with street youths. In-depth interviews were carried out with selected personnel from district health offices, as well as staff from the zonal and district departments responsible for women, children, youth, and social affairs. Additionally, a volunteer working with street youths participated in these interviews. Data collection continued until saturation was achieved. The level of information saturation was determined when the study participants began to express repetitive ideas. In this study, participants shared their real-life experiences and observations.

The FGD was conducted for a time ranging from 1:15 to 1:30 h, and the interview ranged from 0:45:30 to 1:05:00 h.

Trust worthiness

Sufficient data from concerned individuals were gathered in order to get a significant result. Adequate time was spent to get the relabel result. To achieve credibility, data were collected by experienced data collectors and supervisors. Data saturation was taken into account. To ensure dependability, peer debriefing and audit trials are carried out during data collection, translation, and transcription. Data were transcribed and translated on time. The data interpretation relied on the data to avoid the researcher’s point of view.

Ethical considerations

The proposal was approved by Debre Markos University Research and Community Service Office with Ref.no HSC/R/C/Ser/Co/83/11/11. A letter of cooperation was submitted to the respective town administrative labor and social affairs. Informed oral consent was obtained from local administrators, street youths, and legal representatives of minors and youths without formal education. Assent was also obtained from study participants who were minors. Participants were informed that they had the right to refuse participation or to terminate the interview at any point during the discussion. They were also assured of the confidentiality of the information they provided. Participants were assured that they would not face any harm due to their participation in the study. To ensure their privacy and autonomy, codes were given to participants, and participants were informed that the study uses the codes in place of their names in connection with the study findings or in their answers to discussions or interviews. We adhered to the ethical standards outlined in the Declaration of Helsinki, developed by the World Medical Association.

Data management and analysis

Appropriate audio recording equipment was used. Recordings were stored securely and in a way that protected participants’ privacy. Backups of the recorded data were made regularly to prevent data loss. The data were transcribed accurately word by word, including nonverbal expressions, and translated into the study language. Manual inductive thematic analysis was employed. verbatim transcription was done by the researcher in support of the research assistant. We kept the following qualitative data analysis procedures.

1. Data Familiarization: After transcribing the interviews, we began by thoroughly reading the transcripts to become familiar with the data. This step allowed us to immerse ourselves in the participants’ responses and gain a general understanding of the key issues they discussed related to sexual and reproductive health (SRH) and service utilization.

2. Initial Coding: We used an inductive approach to coding, where we broke the data into discrete chunks of meaning. Open coding was employed, which involves identifying significant statements and labeling them with initial codes that directly reflected the participants’ responses. This process was conducted manually, enabling a more detailed and hands-on understanding of the data.

3. Theme Development: The final themes and subthemes were derived from the data by examining the patterns in participants’ experiences and perceptions. We employed constant comparison throughout the coding process to compare new data with the emerging themes. This ensured that the themes were grounded in the participants’ lived experiences and reflected their core concerns.

4. Finalization and Validation: Once the themes were established, we reviewed them in light of the data to ensure they accurately reflected the participants’ experiences. We also conducted a peer review of the final themes with a colleague familiar with qualitative research methods to ensure the validity and reliability of the analysis.

A thematic map (Fig. 1) was created to illustrate the emerging themes visually.

Fig. 1.

Thematic map of risk factors of sexual and reproductive health problems, service utilization and its challenges among street youths in East Gojjam Zone, North West Ethiopia 2019

Findings

Participant profile

A focus group discussion involved 85 street youths. Ten of them were females. Their educational status ranges from non-formal education to secondary school. Half of the participants had both parents. Two-thirds of the participants were sexually active, but proper utilization of condoms was below 50%.

In the in-depth interview, 8 key informants from the health sector, social affairs, and community members aged 24 to 52 participated. All of these participants were degree holders.

Theme one: risk factors of sexual and reproductive health problems on street youths

Sub-theme 1.1. Low perceived susceptibility for SRH problem

A few streets youth considered themselves as they are free from risky sexual behavior. They perceived that low acceptance of street children in the community hinders the fulfillment of their sexual desire. This condition was negatively affecting their intention to know about safe sexual practices.

“Street children have no chance of exposure to unsafe sexual practices… Even though we have a need, we can’t do anything to cool down our feelings; they (females) are not interested to be our sexual partner since we are on the street….and we are at the lowest level of the population… So, we (street children) are not motivated for sexual intercourse”. Male, 18 years old.

“Those living with their parents may have sexual contact with neighboring girls; otherwise, if you ask one girl something while you are on the street, she might not accept you… She said This is Fedala! (Amharic Word, the name given for street children by considering them betrayal/something) Male, 16 years.

The other inhibiting factor for sexual practice on street youths was economic reasons as they stated.

“To have a sexual partner, we need to have money…there are commercial sex workers…Those who have many might go there but not street children… even though we have a need, we couldn’t do it since it is a business”. Male 17 years old.

Sub-theme 1:2. Having multiple sexual partners

Different stakeholders also stated that having multiple sexual partners, alcoholic drinks, and chat chewing were the main risk factors for RH problems in street youths.

“…In my observation, having multiple sexual partners exposes them to this thing (RH problem). Except for the two youngest girls, all of these male and female street children that you have got here are sexually active. Their sexual partners are commercial sex workers and street children. Some women who are working in business (commercial sex workers) also sleep (having sex) with them (street children) when they have no job…Some female street youths also engage in business with males who are working in the bus station; others are considered as a wife and sleep (having sexual contact) with other individuals.” Male, 32 years old.

Another participant also supported this idea.;

“One of the risks for these street youths is being a partner for everyone who ever meets them since they are not under the control of their family. For example, they may have a chance to meet drivers, other movable traders, governmental employees who come for training or meeting;…. they might have a chance to go to other places and practice unsafe sexual intercourse with these individuals…” I3-Male, 48 years old.

Sub-theme 1:3. Alcohol and substance use

Street children reasoned out the effect of alcohol and substance use on their exposure to different RH problems,

“Most of the time our friends come after drinking alcohol during nighttime and say some improper things…Male Street children themselves took you somewhere alone and do whatever they want when we are burning fire for katera (working the whole night on the street )… but it doesn’t mean all of the street children practice this thing. Female, 18 years old.

“The discrimination raised by the community and the pressure applied by police and local administration exposed us to substance and alcohol use… These substances also lead us to have sexual contact… When we have taken a drink, we went to commercial sex workers; if they (commercial sex workers) didn’t apply the condom properly, we might acquire sexually transmitted infections.” Male, 19 years old.

​Here there are many chat houses (houses used for chat chewing and selling) so, there is a tendency to use it… especially all males are using chat, smoking cigarettes and shisha (marihuana) except a few, these may increase the chance of exposure to HIV/ AIDS, sexually transmitted infections and other dangerous activities…there are many children affected in this way.” Male,48 years old.

The types of alcoholic drinks mainly utilized by street youths were Areki (locally prepared alcohol) and collected remnants of beer from Hotels ‘chellie ’(the remnant of beer) as most of the participants stated here;

“…Mostly we are using Esatite (locally available alcohol drinks that cause a burning sensation like fire)’ Arekie ’, laughing and Tella (local beer)…since we couldn’t get other things.” Male,20 years old.

“…It may not be onlyAreki. If we have money, we can drink beer, something that can beat our heads (make them unwind and relax).” Male,15 years old.

“…On the night time there is ‘chillie’ (the remnant of beer)…they bring it free of charge from the Hotels and drink it.” Female,21 years old.

Most of the participants expressed the reason why they were taking alcohol and other substances. The nature of their day-to-day income-generating activities was the one since most of them were engaged in different activities at night. To be alert at their working time, they have to take chat as they stated below:

“Some individuals take chat to prevent sleeping at night since there are so many activities… We are workingJeblo‘selling of soft paper, mastic and condoms until seven local time at night…” Male,16 years old.

Most street youths were using substances due to peer pressure to get pleasure, and to shield their bodies from the cold.

“We start to drink when we meet our friends… we start to drink by observing our friends, then we will continue it. Anyway, when we are spending time together, we might share ideas with our friends or do something to be unbend… I also used this…We feel happiness…,Mirkana (excitement)… since we have no job, we use it ( chat ) to spend our time…the time cannot go if we are simply sitting but it passes when we use chat; we also take‘Chebsi’ (alcohol drinks after chewing chat ) ” Male,17years old.

“Some children who have no night clothes may protect themselves from the cold by smoking cigarettes and chewing chat… ‘Sitozu' (when it changes their feeling), they may not feel the pain whoever beats them.” Male, 19 years old.

“…Especially to be happy, inhaling Mastish (glue) is good. It is also good for sleeping.” Male, 18 years old.

All participants agreed on the positive effect of glue on cold weather conditions.

“In cold weather conditions, we buy it( glue) by sharing money. We poured it into the plastic bottle and inhale through rotation… If you draw mastish ( glue) you may not be exposed to draft…you can resist your hunger, and coldness…. Here it is not found, mostly Chat, Areki, and Cigarette are available”. Male, 18 years old.

Cigarette smoking is common among most street youths.

“Some individuals might be affected by love and start to use Cigarettes just as farce then, then they will continue and become addicted.” Male,17 years old.

Another substance utilized by some street youths is Ganja, which makes them energetic, able to cope with any problem they have faced, be audacious, and traumatize their body with harmful materials, whatever they get, as stated below:

“if you take it (Ganja), you can have the power to resist whatever you face, including the pressure of the police at that time… those who are utilizing it are cutting their body with a blade; even they may cut the neck of street children who are sleeping on the street.” Male,20 years old.

Some of the participants also explained the social and psychological effects of missing substances on them, whereas a few street youths did not face any problems while they were missing chat.

“After you take it (the glue), you feel that you are in another world. If we can’t get it, we will fight each other…around 1 pm (at 7:00 local time), you start to think about it and say that! (Yawn)…I feel that I am in hell.”

“Some of us are using about 15–16 cigarettes in a day regularly. If we can’t get a cigarette, we become sick. We will feel numb and become stupor…. Male 16 years old.

Concerning the source of income for substances, including alcohol, most of the participants have got money by polishing shoes, selling Jeblo (tissue paper, chewing gum, candy…on the street at night), and gambling;

“At least in the daytime they are polishing shoes…they may not have a shortage of money for a chat; they also doJeblo(selling tissue paper and chewing gum) …. In addition, during nighttime, another group playsKumar (gambling).” Female, 21 years old.

Few individuals who are using these substances in the community also have a role in covering the cost of substances for street youths, as participants stated below:

“For chewing and smoking, the community will give you. if you request them to invite you for a meal, they do not accept but, they will give you Tella and other things.…even though they are not giving money, they are giving from what they drink and chew especially those who are working in the bus station and those who have money for chat and alcohol drinks.” Male,17 years old.

Sub-theme 1:4 exposure to pornographic film

Some of the participants considered watching pornographic films as one of the risk factors for acquiring RH problems.

“They are likely imitating what they have seen in movies. There is an Indian film that we call ‘Spartacus’, laughing loudly…. It is a seasonal Indian film that costs two Ethiopian birrs for each individual in one session… Males and females always watch together”. Female, 21 years old.

Theme two: reproductive health service utilization

Sub-theme 2:1. Information

Street youths were not getting any information about reproductive health.

“No!…from the beginning, it is not implemented here…. When I was in Addis Ababa, we had had meeting and they informed us about it, but here nobody told us about it. For the sake of the law, police beat us rather than giving us information…since street children are considered as thief. Their advice is beating.” Female, 18 years old.

“ Here, they told us to be organized and save money. The Police only know about beatings rather than giving information. Here, the community is not supporting us.” Female 18-year-old.

Participants have received information from the community and organization.

“There are some individuals who are advising us not to have any sexual contact at this age; they also told us to avoid borrowing a needle, blade… something. For example, the organization named’ Mulu Tila’ was taught and provided us HIV testing and counseling services.” Male,15 years old.

Sub-theme 2:2. Maternal health service

Few participants utilized maternal health services:

“My child is now grown up;…during my pregnancy, I attained antenatal care starting from three months up to nine months in the health center. I also gave birth there…my child took vaccination up to nine months.” Female 21 years.

“I was faced with unintended pregnancy and attempted an induced abortion due to economic reasons… Safe abortion service was provided to me in the Hospital.” Female, 19 years old.

Sub-theme 2:3. Utilization of condoms and other family planning services

Some of the female youths who had sexual contact for getting money utilized condoms consistently since the nearby health centers and local non-governmental organizations provided them regularly. These individuals also had a chance to get screening tests every three months as they stated here:

“Iam working on business…. When I used a condom, I applied it properly since I needed to be safe. We( sex workers) also have a screening test every three months.” Female 19 years.

No one was utilizing any methods of family planning except condoms. However, condom distribution was mainly focused on commercial sex workers and long-track drivers. Most of the street youths were buying and utilizing it as they stated below;

“I think nobody is going there (health facilities), we are buying from those who are selling Jeblo (those who are selling tissue paper, candy, chewing gum on the street, and food and drinking establishments) or shops…. Since we are selling condoms, we are using from it. But most of them (street youths) are not using condoms.” Female 20 years.

Regarding the techniques of applying condoms, they stated as;

“It is written on what we are selling, and we can see it there. For those who couldn’t read, if they need our assistance, it is a must…we told them what we know about it. Male, 17 years.

Sub theme 2:4. HIV testing and counseling service

HIV testing and counseling services were not provided for this specific group of people in a planned way, as most of the participants agreed on it.

“…they provided counseling service for males in the kebele, but they offer HIV testing if they have got us in the tea room…They (concerned bodies) are mainly focused on businesswomen regarding HIV/AIDS.” Female 19 years.

A few participants reported that they have irregularly gotten HIV testing and counseling.

“We have got the service in the kebele for the last three years, but it was not provided regularly. Male, 16 years old.

Theme 3: challenges of street youths to get reproductive health service

Sub-theme 3:1. Healthcare provider behavior

One of the challenges observed by street children on reproductive health service provision was the unsupportive behavior of health professionals who were working in different health facilities of selected town administrations.

“Even though my case was beyond their capacity, the health care providers in the health center did not respect me, did not refer me to the Hospital on time, and did not provide adequate information about it.” Female,19 years old.

There was some difficulty with HIV testing and counseling for a single individual, as most of the participants stated.

“If you have no sexual partner, health care providers are not willing to offer HIV testing and counselling services. Those single individuals who were interested in knowing their HIV status have received the service during the campaign. In the health center, they demonstrate condom utilization only for adults, but for us, they said that it is not available here, or our age is not appropriate to use it. I think they are providing condoms based on the age of individuals, they offer it after 18 years old. Due to this, one of our friends used plastic bags of chat to protect himself even with similar sex (male to male) since he had debtriod.” Female,18 years old.

“For example, I returned without a condom due to my age. I am sixteen years old. In the bus station, no one could know his age correctly since they were coming in the childhood period.” Male,16 years old.

Sub-thame 3:2. Health system

The health system and availability of inaccurate data on the number of street children is one of the challenges to sexual and reproductive health service utilization of street youths, as stated by one of the government officials.

“Current health system is DHIS which is not incorporating this service… There is difficulty in making the service accessible to them in terms of service delivery period and cost. There is also a problem with implementing and reporting in a measurable way since there is no exact data on this group of people. Now, when you told me, what I was thinking is that, to whom can we give this responsibility? How can we evaluate it?….

Once these children separated from their parents and enter into the difficult situation, not only these children but also all the people in the county are expected to be infected with different infectious diseases widely.” I2- Male,50 Years old.

Discussion

Risk factors

Street youths had no readiness to protect themselves from perpetrators who were attempting sexual violence and becoming exposed to unsafe sexual practices. The primary risk factor that could expose street youths to different SRH problems was their poor perceived susceptibility to SRH problems, which is in line with the previous studies [21, 22]. This might be due to the reflection of the community surrounding them since youths are considered disease-free in the society [4]. Lack of awareness about sexual and reproductive health, the modes of transmission of various STIs, and prevention methods were contributing factors to the existing SRH problems. This is supported by other studies [23–26].

Alcoholic drinks and substances were easily accessible around the street youths’ working areas. They had been using these substances and alcohol excessively. This is consistent with another study [24]. These substances and alcohol enhanced their sexual desire and urged them to practice unplanned and unprotected sexual intercourse. They might go to commercial sex workers, which is consistent with a previous study conducted in Gondar [14]. A commonly utilized alcoholic drink was the residuals of beer ‘chillee’, which is taken from food and drinking establishments without any expense.

The most widely used substances by street youths were Chat, cigarettes, glue, and marihuana. This is in line with the study conducted in Addis Ababa, Ethiopia [25]. The utilization of substances in these groups of people might be high since they are at the stage of eagerness to test new things. Besides this, they could do whatever they wanted since they were not under the control of their family. The other reason was the working conditions of these people. Most of the time, they were engaged in different activities like Jeblo (selling tissue paper and chewing gum), gambling, sex for the exchange of money, and so on, at night. These substances may be used to stay alert while they are at work. Most of these substances maintain their feeling; they give pleasure, excitement, and a sense of bounciness in line with another study [26]. In addition, it prevents the pain released from physical and psychological trauma, which is in line with a previous study [25].

They also mainly used these substances due to peer pressure and to pass their time since they were not fully engaged in work, especially in the daytime, which is consistent with previous studies [26]. If they fail to take these substances, they might face arguments with their friends or the nearby community. They couldn’t even practice their day-to-day activities due to their dependency.

Having multiple sexual partners was one of the risk factors that might increase the chance of getting sexually transmitted infections, which is consistent with other studies (4. 9,13). Most street youths were sexually active and had frequent sexual contact with themselves, with commercial sex workers, and with those individuals who had been considered as a regular partner from bus stations. So, almost all would have sexual contact with different people at a time.

Exposure to pornographic films was also one of the risk factors for acquiring SRH problems among street youths. After watching the film, they attempted to practice what they had observed there, which is consistent with the study conducted in Australia [27].

SRH service utilization

Most street youths had no exposure to SRH-related information. This situation can be attributed to the lifestyle of street youth, who often lack a permanent residence recognized by local authorities or the wider community. As a result, they are frequently excluded from official records and support systems. Furthermore, their limited access to media and information sources hinders their awareness of available services. Governmental bodies such as the Ministry of Health, Youth, and Social Affairs have not adequately addressed the sexual and reproductive health (SRH) needs of this vulnerable group. Consequently, due to this significant information gap and lack of institutional support, many street youths are unable to access or utilize essential SRH services. This is supported by the study conducted in Gondar [14]. However, few of them utilized maternal and child health services. Regarding condom utilization, most sexually active street youths had sexual contact without a condom, which is consistent with other studies [28]. However, those street youths who were engaged in sex for the exchange of money utilized it consistently. The reason might be the easy accessibility of condoms and special follow-up by the nearby health facilities and non-governmental organizations working with commercial sex workers. The same is true for HIV testing and counseling services. They were screened for HIV every third month, but not for other street youths.

Challenges

The unsupportive behavior of health professionals was hindering utilization SRH services by street youths. These might lead them to search other options like using plastic bags of chat as condom or practicing unprotected sexual intercourse. The gap in knowing the exact age of street youths might mislead the healthcare professionals on estimating the age of these street youths. Discrimination by demographic background may affect adolescents’ choice of care and distance them from accessing the existing friendly sexual and reproductive health services [29]. Prejudice towards street youths might influence the perception of healthcare professionals. Since they are part of the community, they might perceive these street youths as a thief, having so many communicable diseases, and having no sexual desire as another segment of the population since they are living on the street. The negative attitudes of the healthcare providers challenged them to access the SRH service [30–33].

Single individuals who had been interested in getting HIV counseling and testing were not allowed to get the service. As we know, these street youths had multiple sexual partners [24]. So, it is difficult to select one as a partner since all had an equal risk of exposure to STIs. Unmarried women and young women are largely excluded from RHS [34].

The health system was also one of the challenges to the utilization of SRH services by these marginalized people. The current health system (DHIS) had never incorporated this service, so service delivery, including accessibility in terms of distance, time, and cost, became difficult. This is supported by other studies [29, 30]. Due to their mobility from place to place in an irregular pattern, there was no exact data on street youths from national to local administration. This might mislead policymakers who were responsible for creating strategies and allocating budget for SRH services since access and utilization of SRH services is low among migrant street children and adults [34].

Limitation

This study was not guided with preexisted theories which are paramount to dig the behavioral pattern of street youths especially on their sexual and reproductive health issues.

Conclusion and recommendation

The utilization of alcoholic drinks and substances, having multiple sexual partners, exposure to pornographic films, and limitation on accessibility of SRH service to street youths were the main contributing factors to the existence of SRH problems. Sexual and reproductive health service utilization by street youths was minimal. The unsupportive behavior of health care providers and the community, along with gaps in health care policy, posed challenges to the utilization of sexual and reproductive health services. So, the health system and policy should take the front-line responsibility for sexual and reproductive health issues of street youths; Ministry of health should consider convenient and accessible reproductive health service programs including continuous awareness creation towards different prevention modalities of sexual and reproductive health problems; town administrations should establishing rehabilitation center, provision of comprehensive psychosocial support and safe working environment; the health care providers as well as the community should give user friendly service for street youths as the general population.

Abbreviations

DHIS

District Health Information System

FGD

Focus Group Discussion

HIV

Human Immunodeficiency Virus

RH

Reproductive Health

RHS

Reproductive Health Service

SRH

Sexual and Reproductive Health

STD

Sexually transmitted disease

Author contributions

AA drafted the proposal, did the analysis, wrote the results and prepared the manuscript. MD and WG participated on editing, analysis and write up of the result. HA, GG and HA were involved on data analysis and manuscript preparation. All authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

All data supporting the study findings are included in the manuscript. Additional detailed information and raw data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted after obtaining ethical clearance from Debre Markos University, College of Medicine and Health Sciences, Research and Community Service Office with Ref.no HSC/R/C/Ser/Co/83/11/11. A formal Permission paper was given to the respective town administrative Labor and Social Affairs. Verbal informed consent was also obtained from the study participants who were above 18 years and from legal guardian of minors after explaining the purpose of the study. Participants were notified that they had the right to refuse or terminate at any point during the interview and discussion. They were also assured of the confidentiality of the information they provided and would not face any harm or benefit due to their participation in the study.

Consent to publish

We have received informed oral consent from participants for possible publication.

Competing interests

The authors declare no competing interests.