Factors associated with access and utilization of sexual abuse emergency healthcare services among street children in Zomba, Malawi: a qualitative study

Abstract

Background

Sexual abuse among street children is a problem that renders a burden of sexually transmitted diseases, HIV infection, and early pregnancy. Literature shows that globally 95 million children experience sexual abuse with 1 in 5 girls and 1 in 7 boys exposed to sexual abuse before 18 years of age in Malawi. Malawi adopted the World Health Organization guidelines for providing emergency health services for victims of sexual abuse, which include HIV Post Exposure Prophylaxis (PEP) and Emergency Contraceptive Pills (ECP) within 72 h of exposure, Sexually Transmitted Infections (STI) treatment, and psychosocial services. However, there are challenges associated with the services that limit access and utilization among street children. This study explored the factors associated with access and utilization of sexual abuse emergency healthcare services among street children in Zomba.

Methodology

This was a cross-sectional phenomenological qualitative study conducted in Zomba City from 2022 to 2023 using in-depth and key informant interviews. We purposively selected street children between 10 to 17 years who have been exposed to sexual abuse on the streets and social actors working with street children. The study employed a thematic analysis approach.

Results

The study found that street children did not utilize sexual abuse emergency health services. The major factors associated with utilization included the knowledge of sexual abuse, its associated health risks and sexual abuse emergency health services, and perceptions of utilizing sexual abuse emergency health services. The barriers to utilization of sexual abuse emergency health services included perceived shame, fear, discrimination, prolonged treatment process, and attitude of the health service providers.

Conclusion

Sexual abuse and its health risks continue to be a challenge among street children. The absence of adequate connections and secure environments for street children to report sexual abuse and seek help without facing judgment has created significant obstacles for them in accessing sexual abuse emergency health services. To curb this challenge it is crucial for successful interventions to specifically address the health needs of street children and involve them in the decision-making processes related to their interventions.

Background

Globally there are approximately 150 million street children [1]. More than 40 million street children live in Latin America and at least 18 million in India [2]. It is estimated that around 2 million children live on the streets in Pakistan [3]. An estimated 10 million children in Africa live without families, mostly in towns as 'street children [4]. Nearly 250,000 South African children live on the streets [5] Street children are a nomadic population as such no recent surveys have established the current number of street children in Malawi [6]. However, approximately 15,000 children live and work on the streets of Malawi's major cities [7]. Street children are usually neglected, misunderstood and deprived of their human rights placing them at different health risks including exposure to sexual abuse [1, 8].

Globally, an estimated 95 million children experience abuse annually, with the highest rates reported in the World Health Organization (WHO) African region [9]. In Malawi sexual abuse among street children is a neglected health problem that renders a double burden of HIV infection and adolescent pregnancies [10]. About 1 in 5 girls and 1 in 7 boys are exposed to sexual abuse before 18 years of age [11]. Evidence has also estimated the prevalence of HIV to be 4.6% among children subjected to sexual abuse and that 33% of girls exposed to sexual abuse become pregnant [11, 12].

Acknowledging the rise in sexual abuse globally the World Health Organization developed guidelines for providing emergency health services for victims of sexual abuse, which include HIV Post Exposure Prophylaxis (PEP) and Emergency Contraceptive Pills (ECP) within 72 h of exposure, Sexually Transmitted Infections (STI) treatment, and psychosocial services [13]. For victims of sexual abuse these services assist in preventing health problems of HIV, unwanted pregnancy, and mental health [13, 14].

In 2012 the government of Malawi (GOM) adopted WHO guidelines for providing emergency health services for victims of sexual abuse [13]. However, street children have never been considered an at-risk population [15]. Studies have also indicated that many services do not meet the specific needs of street children and do not offer complete services which may stunt recovery for some children [16]. Studies have highlighted that street children are particularly vulnerable to sexual abuse which often leads to health problems such as HIV infection and adolescent pregnancy [8]. Moreover, existing studies have also shown that the marginalised intersectional identities of street children make it difficult for them to access and utilise emergency health services. Despite these findings no research assessing the accessibility and utilization of sexual abuse emergency health services among street children in Malawi. To establish sustainable connections for emergency health services specifically tailored to street children affected by sexual abuse, it is essential to gain a deep understanding of their experiences and health needs. This involves exploring their access to and use of such services, to ensure these interventions are effectively designed to meet their unique challenges and circumstances. Therefore, this study aimed at exploring the factors associated with access and utilization of sexual abuse emergency health services among street children.

This study was guided by the health belief model. Originating in the 1950s the model was developed by the US public health department [17]. The health belief model states that people's beliefs influence their health-related actions and behavior [18]. The HBM postulates that the subjective views that individuals have about their health can be utilized to predict their health-related behaviors. Khalif et al. utilised the Health Belief Model as a determinant model that was most used to explain that one’s health behavior may be affected by individual beliefs and perceptions toward certain diseases [19]. Studies in Ethiopia used the HBM to assess HIV prevention practices and associated factors among street dwellers [20, 21].

In this study, the model helped in developing the study guides, data analysis, and developing themes. The constructs helped in exploring the lived experiences and barriers to access and utilization of sexual abuse emergency health services. The two constructs of the model–perceived susceptibility and severity–relate to an individual’s risk perception of health behaviour. The other constructs, perceived barriers and benefits, are related to the individual’s decision-making and the likelihood of action. The Health Belief Model (HBM) was an effective framework for comprehending the perceptions and actions of participants.

Methodology

Study setting and design

This study employed a cross-sectional phenomenological design to capture the narratives of street children on the utilization of sexual abuse emergency health services. The phenomenological approach investigates the everyday experiences of people while suspending the investigator's preconceived assumptions about the phenomenon [22].

This study was conducted in Zomba City, which has 70% of its population falling below the poverty line, causing a lot of children to enter the streets in search of better living [23]. Despite the lack of enumeration, a report from district social welfare officers indicated Zomba as one of the districts facing high numbers of street children due to child neglect and poverty [24]. Zomba is the second district with a high prevalence of HIV in Malawi at 13.5% [25]. There was no figure of the magnitude of the Sexual abuse of street children because sexual abuse cases are rarely reported to legal institutions. However, the city is surrounded by semi-urban locations that breed immoral behaviors like pornography leading to a rise in sexual abuse cases [24].

Sampling and selection of participants

We used a non-probability purposive sampling of the study respondents and interviewed 23 participants. Purposive sampling was used to select the sample based on the population characteristics and the objective of the research [26, 27]. With the help of a street social worker, we purposively recruited 11 participants who have been on the streets for more than a year and have been exposed to sexual abuse after joining the streets. The other criterion was that the children had to be between the ages of 10 to 17 as this was the age range that was able to comprehend their lived experiences and explain their narratives. Snowballing technique was also used to recruit 12 because it was difficult to access street children, especially girls therefore, using their networks of relations was an important aspect. We informed participants about our study and selection criteria and asked them to share the information with friends who they know have the same experiences and if the friends agreed to do the interview they reached out to us and screened for eligibility and then scheduled time for the interview. The principle of saturation was used in this study as a criterion for determining when to stop sampling participants. We therefore stopped collecting data when the research question was answered comprehensively and there was no emergence of new codes and themes.

Data collection

Data were collected using individual in-depth interviews with an interview guide. The interview guides were developed and translated into Chichewa by the principal investigator, and the second author reviewed them (see supplementary appendix 1). In-depth interviews are regarded as most suitable for exploring individual experiences of handling and reporting sexual abuse incidents [28]. The principal investigator and a research assistant conducted all the interviews. The participants were interviewed at a mutually agreed time and setting to ensure comfortability, privacy and absence of noise as sexual abuse is a sensitive topic.

The interviews for the street children were conducted in Chichewa. Nonverbal communication was also captured. In the process, the participants took the lead in describing their experiences living on the streets and their exposure and response to sexual abuse. Our role was asking open-ended questions, asking for clarification, using standard and specific probes, and taking field notes together with the tape recording. We also interviewed key informants; two social welfare officers (from Zomba City Council and Zomba District Council), two health care providers (Zomba Central Hospital) one police officer in the Victims support unit and two adults living and working on the streets with the street children.

Data management and analysis

The tape-recorded data were transcribed verbatim and translated into English. Data were stored securely, and audio files were saved using a password in a computer folder. The data were analysed using a thematic analysis. The thematic analysis involves reading through a dataset and identifying patterns of meaning across the data to derive themes [29]. Thematic analysis is an appropriate method for understanding experiences, thoughts, or behaviours across a dataset [30]. We first familiarised ourselves with the data by actively reading the interviews, observations, and field notes and then generated initial codes by taking notes on potential interests and connections. We created a codebook with the help of Nvivo 14 software which was used for gathering and organizing the data. The coding framework was deductive, where we identified data related to the study objective and the theoretical framework that guided the study (HBM), and inductive, reflective of pertinent issues raised by the data. The third step examined the coded and collated data extracts to identify potential themes of broader significance. The themes were reviewed, and the revision ended once all relevant data items were incorporated into the coding scheme. After refining, we created a definition and narrative description of each theme, including why it was important to the broader objective of the study. In this step, we selected data extracts to be presented in the final report that illustrate key features of themes and create narratives surrounding them that provide context to explain their importance to each theme's broader story. This final step involved writing the final analysis and describing the findings.

Ensuring research quality

Ensuring qualitative research quality is vital for the trustworthiness of the research [31, 32]. The major criteria used to determine trustworthiness were credibility, transferability, dependability, conformability, and reflexivity.

Credibility

This is concerned with the aspect of trust value and involves how the details of the study are relevant to the participants' experiences [32, 33]. The author had prolonged engagement with street children during the interviews to evaluate the study’s environment and context. The author also built a rapport by working with familiar people, such as social workers working in the streets of Zomba city and having informal chats with participants to build a relationship with them. In addition, the fact that the author has worked as a social worker in Zomba made it easy to build rapport due to familiarity with the landscape of Zomba City and the livelihood of street children. Triangulation was conducted by checking the major findings against the health belief model to increase accuracy.

Transferability

Transferability is the extent to which a study provides contextual information about the study phenomenon [33]. In the study, apart from describing the lived experiences of street children the first author also explained the reasons why street children joined the streets and also the context in which they live, that is the working and living conditions of street children. The findings of this study can be applied to a group of street children with the same socioeconomic characteristics.

Dependability and confirmability

Dependability involves the consistency and conformability of the neutrality of the study [32]. The first author went through the coding process several times before making the final decisions for the themes. The transcripts and code book were shared with the second author to assess the accuracy of the thematic analysis process.

Reflexivity

This is being aware of the author’s role in the data-collection process [32]. As a social worker working with street children, the first author examined the concepts and assumptions regarding sexual abuse among street children. The author also jotted down these assumptions and preconceived notions before the interviews to ensure that they did not influence the data collection.

Ethical consideration

We Sought and got approvals from the College of Medicine Research and Ethics Committee (COMREC) (Approval number P. 11/22/ 3886) and the Zomba city council to conduct the study. All the participants in the study were under the age of 18. Children are considered ‘knowing subjects, and parents are considered the ultimate authority over children’s participation in the research [34]. Street children, on the other hand, have no parents or guardianship on the streets, and finding parents, if they exist, is difficult. Therefore, it is essential to consider issues that balance the protection of children while progressing in their participation [35]. It is also necessary to ensure confidentiality and privacy in a sexuality study; it is therefore not possible to secure informed consent from the parents of street children [35].

We obtained detailed written and verbal informed consent for the study directly from the respondents, including their agreement to the dissemination of findings through publications. The Consent stated the purpose of the study, potential risks and benefits of participating in the study, strategies for ensuring confidentiality and privacy and participants’ right to withdraw from participation at any stage of the study. We ensured that each potential participant had a clear understanding and conveyance of the purpose, procedure, potential risks and benefits and the voluntary nature of the study, were sober, competent, and provided their full, informed consent before participating. Children advocates, such as social workers working with street children and guardians, were involved in the consent process as witnesses. To protect the integrity of the participants’ data, the following was done: all participants enrolled in the study were assigned a random code number, and no names were used. This code number was used for all information collected from participants, including consent forms and audio recordings. The relationship between data collectors and participants was non-hierarchical and reciprocal throughout the process, as the former wore casual clothes and avoided wearing makeup during data collection to act as insiders and build rapport quickly. Since children were delayed from their respective work and activities by participating in the interviews, refreshments were provided for them.

Findings

We conducted 23 IDI’s of which 19 were male and 4 of them were girls. The participant’s years on the streets varied from 1 to 7 years with the majority of the participants being street children for more than 4 years. (See Table 1) (Page 37).

Table 1 Demographic Characteristics of Street Children (n = 23)

Emerging themes

The main themes for this study were; the knowledge and exposure of sexual abuse and its associated health risks, the individual experiences and perceptions of sexual abuse, individuals' experience of risks and health conditions following sexual abuse, individual experiences and perceptions utilizing sexual abuse emergency health services, and perceived barriers to access and utilization of sexual abuse emergency healthcare services among street children. (Table 2).

Table 2 key themes and sub-themes

Knowledge of health risks and conditions associated with sexual abuse

This study looked at the knowledge of street children on the health risks and conditions that come about when a person has been sexually abused. The interviews indicated that a few children knew about the risks and health conditions of sexual abuse. For the children who knew about the health risks that come about due to sexual abuse, they cited gonorrhoea, syphilis chancroid, and HIV as the main diseases that can be transmitted when one has been abused with chlamydia being the most common STI amongst the street children.

“There are a lot of consequences that come due to such behaviors some of them are the contraction of STIs and HIV and AIDS sometimes death in terms of mathanyula when it comes to sexual behaviors of people of the same sex.” (IDI Participant 19)

Some of the participants did not know of the risks or health conditions associated with sexual abuse whilst others mentioned conditions like scabies and cancer as some of the health conditions that come about after one is sexually abused.

“I wouldn’t know some of the risks but I know Scabies are transmitted when has experienced sexual abuse.” (IDI Participant 7)

Apart from the health conditions that street children identified in this study, there were also some other risks that street children identified. Some of the participants talked about the dangers of pregnancy, while others spoke about the risks of same-sex abuse causing stomach problems.

“There are so many risks that come as a result of having sex with different men, and some of these are contraction of sexually transmitted diseases such as HIV and AIDS and unexpected pregnancies.” (IDI Participant 21)

“The things that men are supposed to give to a woman [semen] are dangerous to give to a fellow man. I hear they make a ball in the stomach, and when the ball dries up, you die.” (IDI Participant 8)

Knowledge of sexual abuse emergency health services

In this study, we also examined the knowledge of street children on sexual abuse emergency health services. Most of the participants knew of the hospitals that provided general health services in Zomba District; however, they did not know of the one-stop services that were provided when one had been sexually abused. Some participants also believed that the police were the entry point to receive any services following sexual abuse.

“When they get the disease, then they have to go and start getting medication, or they should go and report it to the police”. (IDI Participant 4).

There were also a few participants who did not know what services were given to an individual who had been sexually abused. Some mentioned the pharmacy as the place one would go to get sexual abuse emergency health services.

“Some people go to general hospitals, some municipality clinics, and others the pharmacies.” (IDI Participant 8).

Many of the participants did not know of the 72-h timeframe in which one was supposed to receive treatment if they had been sexually abused. Street children mentioned random times from hospital opening times spanning a year.

“We do not receive treatment but maybe in a year, I feel like when you tell other people about the abuse they cannot believe you because of that status of street child.” IDI Participant 5).

The lack of knowledge of sexual abuse emergency health services in street children was due to a lack of sensitisation of the services and training on how to respond when faced with sexual abuse. One key informant said that he had never participated in any sensitisation of street children to sexual abuse emergency health services throughout his career.

“I haven’t been in a situation or scenario where we have been briefing these children alone about the abuse, what the consequences of abuse are, and when they are supposed to report it. I have never attended such a function, but because this office is very wide, my colleagues might have done that because sometimes we can have activities and the whole office knows. Still, sometimes it is to the few individuals who have been assigned by the DSO that is the one who can say ABCD, but so I cannot speak openly to say it has not been done, but to me personally, I have never.” (KI participant 3).

The lived experiences of street children on access and utilisation of sexual abuse emergency healthcare services

The individual experiences and perceptions of sexual abuse

The study revealed that many street children have experienced sexual abuse and have seen it happen to their peers. The participants experienced the following types of sexual abuse: rape by unfamiliar adults on the streets, unprotected transactional sex, and rape by their peers on the streets.

Rape by unfamiliar adults on the street

Rape was common among the study participants. Many of the participants had been raped and had witnessed their friends being raped in their presence. Adults on the streets take advantage of street children living in the streets and rape them.

“What happened was that I was with my friend at Mponda Primary School chatting, then I was surprised to see a man with a child with chips in his hands and another plastic bag with things we do not know of. He took him and went into the bushes, then told him to remove his clothes and started sleeping with him. That is when we ran to tell our friends to see what was going on. When we started rushing back to the scene with people from the bus depot, we found the man gone, and the child remained. Then people questioned him about what had happened. He said the man took him to a restaurant while doing some piecework, telling him he wanted him and the reason would be discussed later. Then he gave him the chips and told him to go and buy other things in Shoprite. That is when he took him to the hill, told him to take off his clothes, and raped him.” (IDI Participant 10)

Rape by peers on the streets

Many of street children are raped by their peers on the streets. This is very challenging for them because these are people they interact with daily, and sometimes being raped becomes a routine.

“I was raped by the boys in town. I was going to get my bottles and money they stopped me beat me up closed my mouth then started doing what they wanted. Afterwards, I just ran (IDI Participant 12)

This form of sexual abuse was echoed throughout the interviews with other participants in the study.

Transactional sex

Some street children are involved in transactional sex, where they sleep with people in exchange for food, protection, or money. This is common with female participants, as three out of the four females in the study had experienced transactional sex.

“That happens a lot. If I tell you to wait until around 8 or 9 pm, we should pass on some road, we will be called. They will even act like we are a repeat customer, asking if you are not coming today. You will ask, do you know me from somewhere? (Zinalowa china pano¹).” (IDI participant 15).

“I must say I have gone through better circumstances, but not all good. Some people lie to you like they will buy you things like a phone, and in the end, they do not hold the end of their bargain. We move on and go separate ways and never meet again. When they call you, I better not go again” (IDI Participant 2)

Many of these street children are exploited as people who offer to pay them do not meet the end of their bargain; they sleep with the children and, ultimately, threaten them or beat them up.

“Yes, sometimes they beat us when we ask for money after getting our services with the aim that we should not collect our money from them. Being forced to have unprotected sex.” (IDI Participant 21).

Individual experiences of risks and health conditions following sexual abuse

The impact of sexual abuse on street children was realised through narratives of their psychological, social, and physical risks. Participants who have been sexually abused experience psychological issues such as trauma and anxiety.

Physical risks

Physical abuse was also a risk factor in this study. Many children repeatedly experience sexual abuse from their peers, and in the process of resisting abuse, they are beaten. One participant was injured while escaping sexual abuse.

“For us boys, some force us to sleep with them so that we should act like girls, but we refuse. They forced us to the extent that this other day this scar, they stabbed me when they wanted to rape me. I escaped, but they found me and stabbed me.” (IDI Participant 16).

Some participants had sexually transmitted diseases after the abuse. One participant contracted HIV after being raped.

“As I am talking. I am HIV positive, and some of the diseases that are contracted and transmitted through sex are syphilis, chlamydia, and candidiasis, to mention a few. Some of my friends have such kinds of diseases. Someone raped me, and after some time, I started feeling unwell. I was getting sick now and again. I went to the hospital so that I could receive treatment. Still, nothing was changing and up until I thought of going back to the hospital to get tested so that I should know what exactly was happening in my body, that’s when I discovered that I was HIV positive.” (IDI Participant 20)

Psychosocial risks

Street children who have been sexually abused demonstrate psychological risks such as trauma, stress, and shame. One of the participants believed that her life had been destroyed ever since he was sexually abused, causing her to feel worthless.

“It [being sexually abused] affected me so badly because that was the time I moved from the village and came here. That was the time my future was destroyed.” (IDI Participant 21)

Some smaller children cry when they recall their abuse because they feel helpless.

“Yes, you find yourself sad and worried and crying when you remember being beaten and everything. You start crying on your own. I am worried all the time that these things happen. I do not like it.” (IDI Participant 12)

Many of the participants were ashamed of their situation and did not want their peers to find out because it shows them as weak on the streets, which is not good for survival on the streets.

“We are ashamed, we cannot even tell our friends let alone a stranger about our situation.” (IDI Participant 13)

Individual experiences and perceptions utilising sexual abuse emergency health services

This study explored the individual experiences of street children after encountering sexual abuse. Many of the participants did not take immediate action to seek medical help following their sexual abuse experience. Street children responded and copied the health risks that came following sexual abuse in different ways.

Coping with the risks of sexual abuse

We identified the strategies that street children use to cope with sexual abuse. These strategies also demonstrate perceived susceptibility to risks and health conditions following sexual abuse.

Self-blame was one-way street children used to cope with the risks of sexual abuse. One participant explained that they were the ones who chose to look for a good life in town. As such, there is nothing they can do about sexual abuse other than be strong on their own since they have no one to protect and advocate for them.

“The big issue is there is nothing we can do. We all want a good life on the streets, food, and piecework, so we allow these situations to happen. We will then see what we can do. We will run, but we don’t have anywhere to lean on. If we had somewhere to depend on for protection, we would have said these are the solutions, but now we are just children. I am the oldest in my group, with my friend standing over there.” (IDI Participant 16)

Alcohol and substance abuse

Some participants turned to alcohol and substance abuse to forget their situation. One of the participants who had experienced abuse through her job as a sex worker said she had no choice but to focus on her work to earn money. As such, she turned to alcohol to numb her experiences.

“There is nothing I can do apart from my job because it’s the only job that helps me find money to earn a living and support myself each day. Mostly, I drink alcohol, and sometimes I talk to my friends.” (IDI participant 20).

Normalising sexual abuse

Sexual abuse is a common phenomenon among street children to the extent that they have normalised their experiences when they are abused. One of the participants said that he saw that some of the smaller street children were in clicks with their abusers.

“Some of these people put themselves at risk of abuse; they deliberately go to the people who are abusers you see.” (IDI Participant 6).

To sum up, these coping strategies have made many street children refrain from utilising sexual abuse services as they have formulated their ways to go around the situation without disturbing their day-to-day lives on the streets. As such, they do not feel like they are susceptible to the risks of sexual abuse. Street children have observed their peers experiencing sexual abuse and continuing with their lives without facing severe consequences like death. As a result, they believe they won't face significant risks themselves and do not seek medical help after such an encounter.

Personal experiences reporting sexual abuse

When discussing what to do when they have been abused sexually, many participants were hesitant about reporting to the authorities. Some of the participants believed that it was not a necessary route to take because sexual abuse occurs frequently, and they could not just report each occurrence. Some street children believed that no one could believe them because of their perceived status as street children.

“I did not report anywhere. It is just part of life here on the streets we just run.” (IDI participant 11).

“Because if we tell anyone, no one will believe us since we are street children.” (IDI Participant 5)

On the other hand, some street children tried to take action and report their abusers. However, they reported to the leaders of their cliques on the streets, who in turn reported to adults on the streets. While they showed interest, the issue quickly died down without proper solutions as they tried to resolve it among themselves on the streets.

“When it comes to where to go, we just resolve it on our own. We have our leaders in the groups that we have. We can tell him, and he can tell other older people, and then the issue dies down there.” (IDI Participant 6)

Some of the participants were willing to report. Still, they were afraid because they believed that the authorities were already onto them and reporting would just get them arrested as they were giving themselves to the police who had previously conducted operations or sweeping exercises to remove them from the streets.

“Because the police are also onto us. Yes, they send us to Chirwa Reformatory Centre where we just sit around doing nothing, making us work as if we are slaves.” (IDI Participant 8).

Some threats experienced by participants came from their abusers and peers. Since the perpetrators are sometimes their fellow street children, they threaten not to tell anyone because they will beat them. One of the participants was beaten to share his experiences with his friends.

“They threatened me that if I tried and told anyone, they would beat me up, but I was with my friends at the river bathing the other day. I told them what had happened, and they also beat me up, so I left everything at that. I wanted to go, but no friend could escort me, so I was afraid. I just said I would hide this.” (IDI Participant 12).

Street children have perceived reporting sexual abuse as a threat as they face a lot of resistance from within, their peers, family, authorities, and the community at large. As such, they would rather suffer in silence than report any cases of abuse. These cues have made street children avoid the utilisation of emergency health services.

Perceptions of utilising sexual abuse emergency health services

Most street children do not utilise one-stop clinics found in hospitals. Some participants said they never thought of going to the hospital because of sexual abuse.

“I would be lazy to do that. I don’t think of the hospital very much.” (IDI Participant 11)

“No, I did not. We usually go if we are suffering from a different illness other than abuse.” (IDI Participant 12).

Some participants visited the hospital when they experienced symptoms of illness. One participant who was sexually abused sought help after falling ill.

“I went to the hospital when I realised that I was sick. I did not do anything after I was abused, and when I got sick I went to the hospital, they tested me and told me the name of what I had I had just forgotten. Oh, syphilis.” (IDI participant 1)

The participants demonstrated a lack of self-efficacy, which was related to the perceived severity of the risks of sexual abuse to their health.

Lack of knowledge on when to seek emergency services after abuse

Street children who have opted to utilise emergency health services usually miss the timeframes that one has to follow when they have encountered sexual abuse, with most of them visiting the facilities when they show signs of feeling symptoms of an illness. Some participants said that they visited the hospital when they saw that they had contracted a sexually transmitted disease.

“Since the abuse happens at night, we wait until morning for us to go, but we sometimes don’t go. We only go when the situation of one of us is not good, so we don’t go instantly because it is usually at night.” (IDI participant 16).

“When I was abused, I got sexually transmitted diseases. I went to the hospital, and they gave me medication. I went when I realised that I was sick.” (IDI Participant 1)

While they perceived the delay in visiting the hospital as a problem, some participants blamed the process of getting help as the reason why they no longer went to seek help again.

“I didn’t go immediately because by that time I was just feeling okay, but after a week, I got seek, and that is when I visited the hospital to receive help, and I explained everything that happened to me lately, and the doctor said I should go to the police and report this case.” (IDI Participant 22)

By the time the street children decide to go to the hospital, they are already exposed to sexually transmitted diseases, including HIV and AIDS. The girls are sometimes already pregnant. Street children’s decision-making on when to utilise health services is a threat because sickness is the only reason they go to the hospital. Without any form or signs of sickness, sexually abused children do not go to the hospital to receive emergency health services that are offered.

Perceived barriers to access and utilisation of sexual abuse emergency healthcare services among street children

The perceived barriers of street children were discrimination, fear, shame, time for treatment, and negative service provider attitude.

Discrimination

Some children do not utilise health services because of their perceived experiences at the hospital during treatment for illnesses other than abuse alone. Their prior experiences of discrimination may bring about fear and anxiety causing a broader apprehension to seeking medical help. One participant said they experienced discrimination, as they did not want to experience it again.

“We find ourselves being discriminated against everywhere at the hospital. They don’t care for us, as you can see from how our clothes are sometimes dirty. We are ashamed, but we are supposed to be helped fast at the hospital, receiving different medications so that maybe we should not contract diseases. Also, the police were supposed to protect us.” (IDI participant 16)

Discrimination was rampant because of the perceptions that society has of street children as an immoral minority in our communities, including those working in key areas in response to sexual abuse.

“The other thing is some of the providers, yes, they are trained, but they lack some of the refresher training, you know, the issues of street children they are marked as an immoral group and condemned, so most of the providers may not be comfortable attending to them it may not be a big problem to them however we need some orientation, some training for the providers so that they should be able to support the street children regardless of their situation and regardless of their identification as street children.” (KI participant 1).

Fear

Some of the participants, specifically girls, were afraid of being exploited by authorities. One girl said that, as a sex worker, it was inevitable for the authorities to ask for sex in exchange for assistance to be sexually abused.

“Sometimes we fail to report to the police stations about the problems that we are facing because some of the police officers ask for money for us to pay them, and sometimes, they also ask us to offer them sex for us to get the help we need.” (IDI Participant 20)

Some street children are afraid of their perpetrators, as they know that asking for assistance means the perpetrators will also be found or be aware of the situation. In this case, they are at the threat of being beaten by the perpetrator of their peers as a snitch. This is a significant street issue, so many children do not act on the abuses they face daily. One participant perceived some of the perpetrators of good social standing as blocking all his advances in seeking health services.

“The biggest reason is that when you report, they can get arrested, but when they come out, we are the ones who will suffer because they say we are stupid kids. You wanted me to serve a sentence, and they abuse us, so we leave it because we are afraid of what may be. The mistake is people will tell you that this one is the one who reported you.” (IDI Participant 18)

Some children did not utilise emergency health services out of fear of being blamed for their situation. Some participants had experienced being faulted for exposing themselves to sexual abuse because of their living conditions.

“People will always scold you and say it is your fault you have brought this upon yourself, so I just feel like that is not a good thing, and if that is the case, it is better just to leave it as it is.” (IDI Participant 2)

Shame and self-blame

Some of the children were embarrassed that they experienced abuse and that they did not want other people to help them or know their situation. This was recurring throughout the dataset. Sexual abuse severely damages a child's trust in others, unfortunately, this can stem from sexual abuse emergency health service providers. The stigma from abuse may also be a deterrent to street children, some may worry about what their peers will think about them which can cause isolation. One participant felt ashamed and alone.

“To be honest, I was also ashamed. I was ashamed, and there was no one to escort me.” (IDI Participant 12)

Street children want to feel valued and comfortable when receiving assistance. With the level of individualism they have garnered on the streets, they have trust issues, making it difficult for them to get assistance from someone who does not show compassion. Street children also believe that being a street child is a significant barrier to utilising emergency health services.

“Being homeless is the key hindrance. I feel like when you tell other people about abuse, they cannot believe you because of the status of a street child.” (IDI Participant 5)

Negative provider attitude

Many street children do not receive medical help following abuse because they believe that service providers also view street children in a different way than an average person. Most participants felt they were in the wrong when receiving treatment from service providers.

“I am also seen as the perpetrator there asking me how it was possible to be raped and how I allowed it to happen to me.” (IDI Participant 13)

On the other hand, children's perceptions varied as they met different services (good and bad) when they visited the hospitals.

“We find that other doctors are very tough whilst some are good.” (IDI Participant 8)

“Let’s say it just depends on the one who is responsible for your case. Some people are helpful, and some are not.” (IDI Participant 19)

One of the key informants conquered that service providers sometimes do not care about the wellbeing of street children.

“Okay if the children find us with sexual abuse issues we first ask them what happened to have the information for the police to take action. However, I should not lie that there are proper steps that are taken because these children are nomads and because of this even the police do not show much interest in handling their cases and the children themselves are scared of the police and when you tell them to go to the station they have assumptions that they may remain there. They may agree to go to the hospital but there are still challenges because of the lack of seriousness service providers towards the street children. The problem is that the hospitals regard them as street children and it is hard because some other people are also there to get services who are regarded as normal people and the focus is on them. All they see is that these children insist on being street children so we might as well leave them.” (KI Participant 4).

The participants also experienced neglect when receiving care for other conditions; as such, they did not utilise emergency health services when sexually abused. Some participants also saw a lack of enthusiasm from service providers when their cases were being handled.

“As you know, we are street children whose voices are never heard, and nothing happens even if we report cases like mathanyula and being forced to have sex with different people; due to such challenges of not being treated like any other normal person, we avoid going to places where we see that we cannot be assisted. (IDI Participant 22)

In addition, service providers have seen a conflicting aspect in the implementation of activities that support street children as they perform sweeping exercises and remove the children from the streets but expect the children to come to them to report and receive help following sexual abuse.

“It must come out properly that these children in the streets are afraid. They may know they must go to the police, but they are afraid since we conduct sweeping with them, or they know of the social welfare. Still, we sweep together, and when they see our cars, they run away, so we walk, but they know. They feel they cannot approach us because of the other services we are doing, so we provide some services, but it is not well-packaged support that is supposed to be provided to the kids so they can be assisted wholesomely.” (KI Participant 2)

In summary, most street children are afraid and ashamed and believe that they are being discriminated against and neglected. Overall, these barriers have hindered street children from using emergency health services following sexual abuse.

Discussion

This study explored the factors associated with access and utilization of sexual abuse emergency health care services among street children in Zomba. The study demonstrated a connection between the knowledge and perception that the street children had of sexual abuse and their actions towards them experiencing sexual abuse on the streets.

The study found that street children know about sexual abuse as it is something that is routinely experienced on the streets These findings were similar to those of a study in Zimbabwe, where sexual abuse was known and experienced by the participants [36].

However, street children also had a lack of knowledge of the diseases and risks that one can get from being sexually abused. Some of the children did not know of the risks of sexual abuse and mistook some other health conditions as those that come due to sexual abuse. These results build on existing evidence that only a few street children have heard of the risks of sexually transmitted diseases and HIV/AIDS following exposure to sexual abuse [8, 37]. Similar studies across Africa have confirmed that street children are aware of sexually transmitted diseases and HIV; however, much of the information came from their peers. Hence, there was a widespread misconception surrounding STI and HIV transmission [8, 37, 38]. These results reinforce HBM’s theory that knowledge modifies perceived susceptibility, severity, and threats. We find that sexually abused street children respond differently based on their level of understanding about health conditions associated with sexual abuse. Those with less knowledge are less likely to feel susceptible and threatened by the health conditions from sexual abuse influencing their actions afterwards.

In terms of the emergency health services following sexual abuse, this study demonstrated that many street children knew of the hospitals that provide general health services in the Zomba district; however, they did not know of the one-stop services that are provided when one has been sexually abused. Street children also did not know of the 72-h time frame in which they were supposed to receive treatment if they had been sexually abused. While previous studies have focused on the knowledge of street children on reproductive health services in general [2, 21, 39], this study revealed a lack of understanding of emergency health services following sexual abuse among street children.

The lack of knowledge of sexual abuse emergency health services for street children was due to a lack of sensitisation of the services and how to respond when faced with sexual abuse in general. The results support the health belief model in that lack of knowledge diminishes self-efficacy in street children. Without proper understanding or awareness of available services, street children often lack the confidence to take proactive steps, such as utilizing emergency health services. The lack of self-efficacy is a barrier, as it prevents them from seeking necessary medical help when faced with sexual abuse. Increasing knowledge and awareness of health services could empower street children, enhancing their ability to access the care they need in emergencies.

Central to this study was understanding the lived experiences of street children who had encountered sexual abuse and how they utilised sexual abuse emergency health services. The results indicate that street children experienced the following types of sexual abuse: rape by unfamiliar adults on the streets, unprotected transactional sex, and rape by their peers on the streets. These findings are similar to studies in Ethiopia, Kenya, and South Africa where street children experienced sexual abuse in the forms of rape, sexual battery and exchange and homosexual behaviors from peers [40,41,42].

In this study, street children were exploited by people who coaxed to pay them money in exchange for sexual favours. This study demonstrated that exploitation is not limited by gender and occurs among both male and female street children. These findings add to the study by Addisalem, where female street children experienced the same exploitation [33]. Since exploitation affects children of all genders, our study established that targeted interventions that address the unique and shared vulnerabilities of both boys and girls living on the streets are necessary when dealing with street children facing sexual abuse.

Participants who were sexually abused experienced psychosocial and physical risk. Physical risks included body injuries and sexually transmitted diseases such as syphilis and HIV/AIDS. These findings are consistent with those from studies in Africa [38, 40]. Street children who have been sexually abused demonstrate psychological risks such as trauma, stress, and shame. These findings are also in line with a previous study in India by Savarka, where Sexual abuse was one of the main causes of mental health problems and psychological trauma among street children [40, 43].

The findings of this study showed that street children did not take immediate action to seek medical help following their sexual abuse experiences. The results identified the strategies that street children use to cope with sexual abuse, namely self-blame, turning to drug and alcohol abuse, and normalising sexual abuse. These findings match the strategies observed in the studies by Addisalem and Cumber [33, 37].

The study further explored how coping strategies influenced the utilisation of sexual abuse emergency health services. The findings indicate that the coping strategies have made street children refrain from utilising sexual abuse services as they formulated their ways to go around the situation without disturbing their day-to-day lives on the streets. As such, they do not feel like they are susceptible to the risks of sexual abuse. The findings fit clearly with the health belief model in that if street children believe that they are not susceptible, they will not access and utilise sexual abuse emergency services.

The study findings indicated that street children were hesitant to report their sexual abuse experiences to the authorities. Reporting sexual abuse was not a necessary route to take because sexual abuse occurred frequently, and they could not just report each occurrence. Some street children believed that no one could believe them because of their perceived status as street children. These findings are similar to those of Everson in which the study participants normalised sexual abuse [36]. Notably, street children perceive reporting sexual abuse as of less benefit to them as they do not see any positive outcomes. In this case, where perceived barriers outweigh the benefits, street children do not take action despite understanding their susceptibility.

The study also indicates that some street children have tried to take action and report their abusers. However, the issue quickly died without proper solutions, as they tried to resolve it amongst themselves on the streets. These results are significant in that they highlight how the efforts of street children to receive help following sexual abuse are covered by their support systems.

The results further indicate that street children were willing to report sexual abuse but were afraid to do so because they believed that reporting would just get them arrested, as they were giving themselves to the police, who had previously conducted operations or sweeping exercises to remove them from the streets. These results are in agreement with those from Ethiopia and South Africa [2, 21, 31], which indicate that street children have long-standing harmful interactions with the police, ranging from physical violence to sexual assaults. There is further room to determine the extent of abuse and sexual assault that street children experience from authorities who provide services to them.

The study also found that some threats experienced by street children when reporting sexual abuse came from their abusers and peers. These results may be because the perpetrators are sometimes their fellow street children who threaten them not to tell anyone or else they will beat them. These results should be considered by sexual abuse emergency health service providers when recommending channels for street children when reporting sexual abuse.

The study found that the street children perceived reporting sexual abuse as a threat as they faced a lot of resistance from within, their peers, family, authorities, and the community at large. As such many of these children choose to suffer in silence rather than disclose their experiences or seek help, believing that reporting the abuse would lead to further harm. These findings are crucial in understanding the cues that prevent street children from utilizing emergency health services, as their reluctance to report abuse is deeply intertwined with a broader sense of mistrust and fear of retaliation.

The results suggest that street children do not utilise sexual abuse emergency health services provided in hospitals. Some of the participants in the study had never thought of going to the hospital because of sexual abuse and only went to the hospital when they felt symptoms of illness following sexual abuse. These results are consistent with a study in Indonesia, where 13% of the participants went to the hospital when seriously ill [44].

These findings provide an understanding of the relationship between the perceived severity of HBM and the utilisation of emergency health services by street children. As street children opt to go to the hospital only when they sense that their health has been threatened in a situation where they encounter sexual abuse and have no apparent symptoms, the probability of acting is minimal.

The study also found that service providers have seen a conflicting aspect in the implementation of activities that support street children as they perform sweeping exercises and remove the children from the streets but expect the children to come to them to report and receive help following sexual abuse. These findings add to a study in Ethiopia, where citizens and service providers lack accountability and willingness to act on the abuse that street children face on the streets. [45]. These results explain why street children hesitate to utilise services despite knowing the emergency health services. The uncertainty of whether the people providing services to them are friends or foes cues them to distance themselves from these services.

The findings of the study show that street children who have opted to utilise emergency health services usually miss the timeframes that one has to follow when they have encountered sexual abuse, with most of them visiting the facilities when they show signs of feeling symptoms of an illness. Although they saw the delay in going to the hospital as their fault, they considered the prolonged treatment process a time-consuming activity that interfered with their street businesses, consequently choosing not to go to the hospital after experiencing sexual abuse again. These results are consistent with those of studies by Cumber et al. [46]. These results are significant in that it is possible that by the time the street children decide to go to the hospital, they are already exposed to sexually transmitted diseases, including HIV and AIDS, and the girls, sometimes, are already pregnant. This also explains why street children do not utilise emergency health services as the perceived benefit is minimal, as time is important for the children to make money and find food on the streets.

The results indicated that the perceived barriers of street children were fear, exploitation, shame, and attitude of service providers. Some of the children were embarrassed that they experienced abuse and that they did not want other people to help them or know their situation. These results align with previous studies from Kenya [47]. The results further indicated that some street children, specifically girls, were afraid of being exploited by the authorities. This was also consistent with the experiences of the study by Addisalem and Gamble, in which the police asked for money in exchange for assistance [16, 33].

The findings also indicate that street children do not utilise health services because of their perceived experiences at the hospital during treatment for illnesses other than abuse alone. The children reported that they were mistreated and called names when they went to the hospital for illnesses like malaria. The findings demonstrated that street children have a clear understanding of their standing as a minority in society who are perceived as immoral; as such, they feel discriminated against by service providers and people around them when they attempt to receive health services. The results also suggest that their living and working conditions stigmatise street children. These results add to the evidence from studies in Jabodetabek [44].

In line with the HBM, our study illustrates how perceived barriers to the utilisation of sexual abuse health services impact the decision-making process of street children. These barriers pose threats to street children’s willingness and ability to seek help. This reluctance ultimately leaves them vulnerable and without the necessary care and support. Emergency health service providers should take these results into account when designing and implementing initiatives aimed at supporting street children. This study established that understanding and addressing perceived barriers will help service providers develop more effective strategies to build trust, create safe and welcoming environments, and foster connections that encourage street children to access the medical care and psychological support they need.

Study strengths and limitations

The study captured the diverse perspectives of the participant's lived experiences. The study also identified themes and patterns that can be used in informing policies and interventions for street children. The study, however, was subject to limitations. Firstly the study may not be generalizable to street children who are not from Malawi, but the findings are transferable to street children who share a similar socio-demographical background as the participants of this study. The cross-sectional nature of the study did not capture changes over time but captured experiences and perceptions in a specific context. However, the descriptive methodology, analysis, and interpretations enhanced the transferability of the findings to street children in the same socioeconomic context as the ones in the study.

The study depended on self-reported data that may conform to exaggeration, attribution, and telescoping. We verified findings by recalling our interview with a participant for them to verify their information.

Conclusion

The burden of sexual abuse and its health risks continue to pose a challenge for street children. This phenomenological study explored the factors associated with access to and utilisation of sexual abuse emergency health services among street children. The narratives of street children explained broad themes: the sexual abuse experiences of street children, health risks and responses to sexual abuse, the knowledge of street children on sexual abuse and its related health risks, and the barriers to utilisation of sexual abuse health services.

In theory, the research offers a comprehensive and situation-specific insight into the factors perceived by individuals that contribute to the utilisation of emergency health services for sexual abuse among street children. The research considered street children active participants in society, capable of comprehending and constructing their own experiences. Although this study was conducted on a limited scale, the confidence in the applicability of the findings is strengthened by the consistency of results across various methods and the significant agreement among the street children who participated in the research.

The study confirmed that street children are facing adverse sexual abuse and its associated health risks. The lack of food, shelter, and clothes, has offered an advantage for street children to experience physical abuse discrimination, and sexual abuse. The study also established that street children have no access to the sexual abuse emergency health services that are provided for the first 72 h of being abused. The barriers have been fear, the attitude of health service providers, discrimination and shame. Comprehensive interventions are needed to address the shortcomings in emergency health service delivery for street children who experience sexual abuse. Raising awareness, creating safe spaces, and establishing connections with street children are key strategies to bridge the gap between their knowledge of available emergency health services and their actual use of these services.

This study sought to mitigate the health risks resulting from sexual abuse and enhance the well-being of street children who have experienced such abuse on the streets. The research findings suggest that policymakers, social welfare agencies, and healthcare providers need to formulate informed and inclusive policies that address the specific needs of street children when accessing health services for sexual abuse. Most policies in Malawi concerning street children have primarily focused on providing social protection for both children and their communities. However, the absence of comprehensive information on street children has resulted in the adoption of approaches that have not proven to be effective. For successful policy implementation, it is crucial to include health policies that specifically address the health needs of street children and involve them in the decision-making processes related to interventions.