Health status of street children and reasons for being forced to live on the streets in Harar, Eastern Ethiopia. Using mixed methods.

INTRODUCTION: In Ethiopia, more than four million children are anticipated to live under particularly difficult circumstances. Street children are subject to violence, a lack of health care, and a lack of education. Which denies them the right to live in a secure environment and exposes them to different health problems. Currently, little is known about the prevalence of Streetism, including health conditions. Therefore, this study was aimed to assess the health status of street children and determinants of Streetism.
METHODS: Mixed methods (sequential) were employed from February 1 to 28, 2021. Quantitative cross-sectional study design and phenomenological qualitative designs were applied. Overall, 220 street children were involved in the study. The most common reason that forced the children to resort to a street way of life is to look for a job and quarreled with parents. The data were collected using interviews methods. Chi-square test and multiple binary logistic regression were applied to examine the variations among variables with the health status of street children. Qualitative data were analyzed using the thematic analysis technique.
RESULTS: The study included a total of 220 street children. As to the quantitative study, the majority of study participants (92.73%) drank alcohol regularly. Depression (39.22%) and peer pressure (43.14%) were the most common initiation causes of drinking alcohol. According to a qualitative study report, "Street children are mostly affected by the communicable disease" and… They are addicted to substances like benzene" which had a profound effect on their health." Furthermore, the study discovered a statistically significant association between respondents' health status and sociodemographic characteristics (age and educational status), job presence, and drug use.
CONCLUSION: This study identified the factors that drove street children to live on the streets, such as the inability to find work and disagreements with their parents. The majority of the street children were affected by preventable and treatable diseases. Unfortunately, almost all street children reported drinking alcohol, which exposed them to a variety of health problems. In general, the study discovered that street children require immediate attention. Decision-makers and academicians should collaborate to develop a plan for these children's health and social interventions.

Introduction

The United Nations Children’s Fund (UNICEF) defines street children as "children in difficult circumstances," who are a minority population that has been under-represented in health research for far too long. The street child population has also been divided into two overlapping groups: "of-the-street" children, who have no contact with family and rarely return home, and "on-the-street" children, who often sleep at home but spend the day on the street [1, 2].

According to studies, among the major health issues affecting street children are physical injury, HIV/AIDS, sexually transmitted diseases, sexual and reproductive health disorders, violence and sexual abuse, substance abuse, and mental health problems. They are considered the most vulnerable population; they are severely impoverished and lack access to health care and education. They are also victims of ferocity and are forced to live on the streets, scavenging, begging, hawking in slums, and living in polluted environments [1, 3, 4]. Street children are subjected to violence; denying them the right to live in a safe environment [5-7].

According to the study, children who spend time on the street are at risk of developing health and social problems, as well as bizarre behaviors such as aggression and hopelessness [8]. Due to hunger, malnutrition, and hygiene issues, street children face a variety of issues that have the potential to negatively impact their health [9]. Evidence showed that the most common reasons forced street children to live in the street were escaping abusive parental punishment, poverty, and parental alcoholic behavior [10]. A similar report also showed that deaths of parents and unhealthy relationships of families were causes that force street children to stay on the streets [11].

Worldwide, around 28 million children live in the street, while in Ethiopia’s recent report by the Ministry of Labour and Social Affairs, the number of homeless people in Addis Ababa was around 24,000 in 2018; approximately 10,500 street children and 13,500 homeless adults [12]. Similar evidence showed that in Ethiopia, over four million children are anticipated to live under particularly difficult circumstances [13-15]. They are at high risk of sexual and physical exploitation [16]. Evidence showed that 15.6% of the street children are practicing risky sexual activity, and 61.6% of the street children face health problems [17]. Nonetheless, despite the growing burden of health problems among Ethiopia’s street children, there is no policy emphasis on the country’s health system.

It is now being observed that the number of street children is significantly increasing; however, little is known about the prevalence of the problems, including the factors that lead to being a street child and their health status [1, 18]. There is a lack of comprehensive and adequate information about street children to take action, necessitating the current study to investigate the street children’s health status and factors leading to being street children in Harar, Eastern Ethiopia. As a result, the objective of this study was to assess the health status of street children in Harari City, as well as to explore the factors that contribute to being street children, to assist policymakers, administrators, health program planners, and researchers in finding solutions to the problems.

Materials and methods

Study setting and period

The study was carried out in Harari regional state, Eastern Ethiopia. Harar is located 522 kilometers east of Addis Ababa, Ethiopia’s capital, at an elevation of 1,885 meters above sea level. The region has a total population of 183,344 people, including 84047 rural residents and 99368 urban residents. Since 2006, UNESCO has designated Harar as a World Cultural Heritage Site. Currently, the city is one of the fastest-growing in Ethiopia, attracting many adults and children from the surrounding rural areas and other neighboring cities [19].

Study design and population

Sequential mixed study designs (quantitative and qualitative) were applied. First collection and analysis of quantitative data followed by a collection and analysis of qualitative data was done. The qualitative results was used to assist in explaining and interpreting the findings of a quantitative study. This was done according to Creswell, 2003 evidence of using mixed-methods sequential explanatory design. Quantitative cross-sectional study design and phenomenological qualitative designs were applied. The source population was all street children living in Harar city while all selected street children residing in Harar city during the study period were the study populations. Study participants that are unable to respond to the survey questionnaire during the data collection period were excluded.

Sample size determination and sampling procedure

Street children can be found in a variety of locations throughout Harar. Seven are chosen on purpose because there is a higher concentration of street children in these areas of town known as Arategna, Ajip, Canal, Botte, Shewa ber, Feres Megala, and Andegan Menged. This was accomplished through observation and consultation with key informants working with street children. Because there was no street children list in Harar city’s Social Affairs Office, the researchers compiled a comprehensive, reliable, and appropriate list by registering all street children living or working on the streets. The registration of street children was completed five days before the data collection date. As a result, 502 street children were registered in the seven sub-towns (S1 Table).

The sample size for quantitative data was calculated using the single population proportion formula (n = (Za/2)2p(1-p)/d 2), with the assumptions of Z = 1.96 for the 95% confidence interval, d = 0.05 for margin of error, and p = 0.5 for the prevalence of Streetism, yielding n = (1.96)2(0.5) (1–0.5) / (0.05)2, n = (3.8416) x0.5 (0.5) /0.0025, and since the total population was less than 10,000, we used the reduction formal, and the final sample size was 228.

For qualitative data, the sample size was determined based on the level of information saturation and the variety of ideas among the sub-groups. Data saturation involves sampling until no new information was obtained and redundancy was achieved. Accordingly, twelve focus group discussions (FGDs) with 8 participants from various groups and 6 key informants were carried out.

Participants include experts from the Women and Children Affairs‟ Office, Police Office, Social Affairs‟ Office, local NGOs, street children’s families, and street children were carried out. These key informants and focus group discussants were selected purposively since they are concerned and more informed bodies in the area. Data collectors have availed themselves in the selected area of the studies in scheduled and pre-planned time to include all street children available in the sites consecutively till the calculated sample size was achieved and for qualitative data, key informants and focus group discussant includes experts from Women and Children Affairs Office, Police Office, Social Affairs‟ Office, local NGOs, street children families and street children as they were more informed and concerned bodies in the area of interest.

Data collection methods and data collection procedures

To fit the local situation and research objectives, the adapted questionnaires were modified and contextualized. For quantitative data, interviewer-administered questionnaires were used. We tried to do our best to adapt a tool named “the health status of street children survey” from measure evaluation which was funded by USAID and undertaken with the title of “children in adverse situations indicators and survey tools and previous literature (BSS tool). The questionnaire includes socio-demographic characteristics of the study participants, life conditions and reasons of Streetism of the study participants, and the health status of street children.

The questionaries were validated before administering to study participants. The first steps were translating the English version questionaries to the local language in the study area (Afan Oromo and Amharic) while keeping the purpose of the questionnaire and the intent of the questions in mind and again translated back to the English language to check the consistency and to ensure the translation’s accuracy. The back-translated version is then compared to the original, and any meaning differences are corrected. The second step was pretesting on the 5% of the respondents who were not eligible for the study before actual data collection. Then the validity and reliability of the instrument were checked. Cronbach’s Alpha was used to measure the quality of our employed instruments. The result was 0.87. Six data collectors and two supervisors were recruited who could communicate in the local language of the study area and preferably had experience in other similar field studies. Every day, the collected data were checked for completeness and consistency. Data collectors and supervisors were also trained. Key informant interviews were used to collect qualitative. A semi-structured interview guide was used. Each key informant’s data was recorded in an audio recorder in a controlled setting to avoid disruption during the interview.

Data quality control and assurance

The investigators and supervisors were made a thorough check for clarity, completeness, and consistency before receiving the filled questionnaire from each data collector. The quality of the data was guaranteed by pretesting using the 5% of the respondents who were not eligible for the study before actual data collection. During the collection of data, questionnaires were cleaned and properly coded.

To assure the qualitative data quality, the key informant interview was recorded using an audio recorder. Member check for the interviews (after the transcription, by summarizing main points and confirming with the interviewee). The initial results were shown for the peers to receive input (Peer debriefs). Moreover, triangulation through different key informant interviews was employed.

Statical analysis

The data were coded, cleaned, edited, and entered into EPI data version 3.1 to minimize logical errors and design skipping patterns. Then, the data were exported to Stata version 14 for analysis. descriptive analysis was done by computing proportions and summary statistics. Then, the information was presented by using simple frequencies, summary measures, and tables. Multivariable analysis was carried out to see the association between each independent variable and outcome variables by using binary logistic regression. The assumption for binary logistic regression was cheeked. The goodness of fit was checked by Hosmer-Lemeshow statistic and omnibus tests. All variables with p<0.25 in the Bivariate analysis were included in the final model of multivariate analysis to control all possible confounders. A Multi-collinearity test was carried out to see the correlation between independent variables by using the standard error and collinearity statistics (no variable with variance inflation factors >10 and standard error >2 was observed). The direction and strength statistical association was measured by odds ratio with 95% Confidence Interval (CI). Adjusted odds ratio along with 95%CI was estimated to identify predictors of the health status of the streets by using multivariate analysis in binary logistic regression. In this study, P-value<0.05 was considered to declare a result statistically significant.

Qualitative data were analyzed using Atlas Ti version 7.1. The thematic analysis technique was used. The recorded data were transcribed and translated. Then the translated data were coded into different codes. Each code was categorized into different categories and then categorized into themes.

Ethical consideration

Ethical clearance was secured from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethical Review Committee (IHRERC). The approval number was IHRERC/016/2021. Before data collection was started, informed, voluntary, written and signed consent was taken from the respondents. For minors (under the age of 18), consent was obtained from their parents and guardians. But for those individuals, without parents, we took assents from children themselves. The institutional health research ethical review committee approved obtaining consent from children that did not have parents or guardians. Any study participant willing to engage in the study and those who want to stop the interview at any time were allowed to do so. Confidentiality was also assured. All the procedures are done per the ethical guidelines of the institution.

Results

Socio-demographic characteristics

A total of 220 respondents participated in the study yielding a response rate of 96.5%. The median age of study participants was 14 years, with an Inter-Quartile range of 4 years and minimum and maximum ages were 5 and 44 years, respectively. Of the total respondents, 78.18% were males. The majority of the participants were Muslims (89.55%). Twenty-eight (12.73%) of the study participants were married. The average monthly income of their parents was 1526 Ethiopian Birrs while the street children got 90.2 Ethiopian Birr on average (Table 1).

Table 1

Socio-demographic characteristics of the study participants and their parents in Harar, Eastern Ethiopia, 2021 (n = 220).

Variables	Category	Frequency	Percentage
Age	below12 years	75	34.09
	13–18 years	120	54.55
	Above 19 years	25	11.36
Sex	Male	172	78.18
	Female	48	21.82
Address before Streetism	Urban	119	54.1
	Rural	101	45.9
Religion	Muslim	197	89.55
	Orthodox	18	8.18
	Protestant	5	2.27
Ethnicity	Oromo	200	90.91
	Amhara	12	5.45
	Hadere	2	0.9
	*Others	6	2.73
Marital status	Never married/ not eligible	185	84.09
	Married	28	12.73
	Widowed	1	0.45
	Divorced	7	3.18
Fathers’ educational status	Illiterate	146	66.36
	Can read and write	27	12.27
	Primary and secondary grades completed	47	21.36
Mother’s means of livelihood	Informal daily laborer	63	28.64
	petty seller/trader	42	19.09
	skilled worker/self-employed	3	1.36
	house servant	29	13.18
	Beggar	12	5.45
	house wife	39	17.73
	**Others	32	14.55
Father’s means of income	Farmer	112	50.91
	Informal daily laborer	48	21.82
	Trader	8	3.64
	Government employee	4	1.82
	Private employee	5	2.27
	Beggar	5	2.27
	Soldier/x-soldier	7	3.18
	Guard	7	3.18
	***Other	24	10.91
Where parents live know (n = 201)	In Harar	62	30.85
	Another urban city	35	17.41
	Rural area	101	50.25
	Don’t know	3	1.49
The reason they leave their place of origin (if parents were migrants)	Drought/famine situation	27	27
	for medical treatment	16	16.00
	To look for a job	34	34
	Don’t know	23	23
Income level of parents	Less than 1000	163	74.09
	1000–2000	30	13.64
	Above 2000	27	12.27

* Others = Gurage, Sidamo, and Somalia

**Others = no work, prostitute, and don’t know

***Other = don’t know and no work.

Educational status of study participants

More than half (67.73%) of the study participants attained primary education(1-4grade) and forty (18.18%) of the street children were never enrolled in the school. The most common reasons hindering them from attending the school include family poverty/financial constraints and family did not appreciate education (Table 2).

Table 2

Educational status of the study participants in Harar, Eastern Ethiopia, 2021.

Variables	Category	Frequency	Percentage
Educational status (n = 220)	Never attain school	40	18.18
	Read and write	18	8.18
	1–4 grade	149	67.73
	5–8 grade	11	5.00
	9–12 grade	2	0.91
Factors hindered from attending school (n = 40)	Family poverty/Financial constraints	28	70
	The family did not attach value to education	6	15
	Had to remain home to help the family	4	10
	Others (bad conduct, too small for education)	2	5
Reason for school dropout (n = 79)	The family could no longer afford the school fee	21	26.58
	I had to work to supplement the family income	21	26.58
	Health/medical reasons	1	1.27
	Expelled because of conduct	10	12.66
	To make my reading	2	2.53
	*Others	24	30.38
If you are given the chance to continue your education now, are you willing to and happy to make use of the opportunity? (n = 79)	Yes	72	91.14
	No	7	8.86

*Others = conflict with family and no reason.

Prevalence of divorce among parents of street children

The magnitude of divorce among parents of street children was 24.63% [95%CI 18.2, 31.8]. The most common causes of divorce were bad habits 10 (31.25%) and disagreement/ conflict among parents 14 (43.75%). The other causes of divorce include poverty 7 (21.88%) and father leaving home to look for a job 1(13.13%). The majority (91.36%) of the streets have parents and about 19(8.64%) children did not have parents. From those who reported they have parents, more than half 134 (66.67%) of the street children’s parents were alive while 48 (23.88%) of street children had only mothers alive (Fig 1).

Fig 1

Prevalence of divorce among parents of street children Harar, eastern Ethiopia, 2021.

Reasons for being forced to live in the street and their life conditions

Quantitative result

This study revealed that the mean length of stay on the street was 3.13 (SD = 3.45) years. Where more than half (55%) of the study participants have lived on the street for less than 1 year. The most common reasons that forced them to resort to the street way of life include looking for a job (26.6%) and quarreling with parents (26.6%). Furthermore, peer pressure (15%), the need for food (8.64%), and the death of parents (5%) were other factors that forced street children to restore ways of life (Fig 2).

Fig 2

Factor that forced the street children to live in the street in Harar, Ethiopia, 2021.

Qualitative findings

As it was clearly shown in Table 3, the common reason forcing street children to live in the street were organized under two major themes include management and stakeholder (Table 3).

Table 3

Explored reasons forcing street children to live in the street in Harar, eastern Ethiopia, 2021.

SN	Theme	Categories	Sub categories	Codes
1	Management issue	Budgeting	Budget to solve problem	B inadequate financial support
				B lack of budget
			Workers incentive	W many workers were turned over
				W workers are discouraging
		Supervision	Assessment	A there was no assessment done yet
				A we don’t have exact data of s. children
			Transparency	T communication gap among stakeholders
				T lack of transparencies among workers
2	Stakeholders	Supporting agents	NGO /volunteers agencies	V rehabilitation center but inadequate
				V focus on supporting food and cloths only
			Governmental agencies	G lack of transparency among workers
				G lack of taking responsibility to solve a problem
				G every one should do something
		Family-related factors	Father/ mother in low	F Loss of family is one factor to live street
				F Father and mother in law also the factor
			Low-income family	I Lack support in food, shelter, cloth, and school
				I They complain to have food and money
			Lack of awareness	Aw lack of awareness on family planning
				Aw an illiterate families /carelessness
		Society related	Attitude	A Lack of Attention towards S children
				A society should discourage substance use first
			Participation	P every one should do something but not yet
				P there is inadequate participation among society
3	The lifestyle and health conditions of street children	The behavior of street children’s	Unwillingness	U street children disobey their family advice
				U unwilling to return to their family
			Substance use	S Usage of an addictive substance, Use benzenes
				S Escaped from rehabilitation centers due to craving
		Health related issue	Sexual violence	S Sexual violence
				Unprotected sex
				S Childbearing age females mostly use implant
			Disease	D they use unclean food from dirty tankers
				D They mostly affected by communicable disease
			Accident	Ac Raped
				Ac Traffic accident

Management related factors.

“There is inadequate financial support! We have a budget problem…Many workers were turned over due to the lack of encouragement! There is no assessment done, to have full information about street children found in Harar! There is lack of transparencies among workers…” (Report from a 32-year-old female working as women and children affair).

Stake Holder’s related factors.

“There are some volunteer centers for rehabilitation named Tesfa, Shalom…in Harar but they are insufficient in comparison to the victims. Some help from volunteers is only focused on something temporary like supporting food and clothes and so forth. But it does not focus on something permanent like rehabilitating and educating… many people are not taking responsibility to solve street children’s problem, but everybody should do something! Father-in-law and mother-in-law should also treat every child. There is a lack of attention towards street children among society…society should discourage substance use first… there is inadequate participation among society…” (Report from a 32-year-old female working as women and children affair)

Quantitative finding

This finding showed that more than half (63.64%) of the streets didn’t have work. Sixty-four (36.78%) of the streets survive by begging while45 (25.86%),36 (20.69%) of the streets survive by carrying small items and serving as a taxi boy, respectively. But eighty-nine (40.45%) of the streets beg even if they have other occupations, and 52.81% of those who beg always beg. Almost half (49.43%) of the streets earn less than 50 birrs per day, with three-quarters (76%) spending it on food. Eighty-four (38.18%) of the streets slept on the verandah (Table 4).

Table 4

Life condition or circumstances of streets in Harar, Eastern Ethiopia, 2021.

Variables	Category	Frequency	Percentage
Do you have work (n = 220)	Yes	80	36.36
	No	140	63.64
street occupation (n = 174)	Begging	64	36.78
	Shoe shinning	4	2.30
	Carrying small items	45	25.86
	Delivering messages	25	14.37
	Taxi boy	36	20.69
Daily income (174)	Less than fifty birrs	86	49.43
	50–100 birr	53	30.46
	more than 100 birrs	35	20.1
Daily income spent on (174)	Food	133	76.00
	Cloth	2	1.14
	School fee	38	21.71
	Help family	2	1.14
Daily income reliable (n = 174)	Yes	27	15.52
	No	147	84.48
With whom were you living before you resort to street life?	With both parents	113	51.83
	With my mother	57	26.15
	With father only	17	7.80
	With close relatives	22	10.09
	*Others	11	5
To whom are you living now?	With my mother	26	11.98
	with both parents	8	3.69
	With relatives	9	4.09
	With father Alone	2	0.91
	With peers/friends	152	69.09
	**Other	23	10.45
Who helps and protects you while you are on the street?	No one	95	43.18
	Siblings	5	2.27
	Peer groups	72	32.73
	Parents	21	9.55
	Close relatives	27	12.27
How often do you usually see/visit your families?	Everyday	41	18.64
	at least once a week	19	8.64
	Once every month	12	5.45
	only a few times in a year	18	8.18
	Rarely	26	11.82
	Irregularly	22	10.00
	Never	18	8.18
	Don’t care	64	29.09
Approve/disapprove of living or working on the street by parents?	Approve	44	24
	Disapprove	59	32.42
	Don’t care	49	26.92
	Don’t know	30	16.48
How many times a day do you eat?	Once	42	19.09
	Twice	82	37.27
	Three times and above	96	43.64
Where do you usually go to sleep?	Home	26	11.82
	church yards	1	0.45
	mosque yards	4	1.82
	Bus stops	13	5.91
	on verandah	84	38.18
	Plastic houses	92	41.82

*Others = friends, wife and husband

**Other = alone and husband.

Health status and substance use among street children

Quantitative results

The majority (61.36%) of the streets got sick in the past month. One hundred twenty-nine (58.64%) of the study participant were hurt by adults while they live in the street. More than one-fourth (27.27%) of the participants had a history of sexual intercourse with someone. Among those, 14.55% had forced sexual intercourse and 8.64% of them had sexual intercourse for sake of money.

Almost all (92.73%) of the study participants drank alcoholic beverages at different frequencies. The most common initiation causes were depression (80, 39.22%) and peer pressure (88, 43.14%). About 60 (27.7%) of the participants used different kinds of drugs like chat chewing, Ganja/Hashish, cigarette smoking, sniff benzene (Table 5).

Table 5

Health status and substance use among study participants in Harar city, Ethiopia, 2021.

Variables	Category	Frequency	Percentage
Have to gotten sick in the past month while living or working on the streets?	Yes	135	61.36
	No	85	38.64
Have you ever been beaten or hurt by adults while living/working on the streets?	Yes	129	58.64
	No	91	41.36
Have you ever had any sexual intercourse with someone?	Yes	60	27.27
	No	160	72.73
Has anyone forced you to do any sexual act?	Yes	32	14.55
	No	188	85.45
Have you ever had any sexual intercourse with someone for the sake of money?	Yes	19	8.64
	No	201	91.36
Which of the following is your immediate need?	Food	76	34.55
	Cloth	10	4.55
	Shelter	16	7.27
	Education	37	16.82
	Family support	14	6.36
	Cash assistance	42	19.09
	Get reunified	19	8.64
	Job	6	2.73
Do you drink an alcoholic beverage like Tela, Tej, Beer, Arekie, and the likes?	Have never drunk	16	7.27
	I have tried once or twice	193	87.73
	I drink most of the time	7	3.18
	I drink daily	4	1.82
What initiates you to use alcohol?	Depression	80	39.22
	Peer pressure	88	43.14
	To protect hunger	20	9.80
	To protect fear (sex, steal)	16	7.84
Do you use drugs?	Yes	60	27.27
	No	160	72.73
If yes, which drug do you use most of the time?	Chat chewing	26	43.33
	Ganja/Hashish,	5	8.33
	Cigarette smoking	12	20.00
	Sniff Benzene	14	23.33
	Mastish	3	5.00
What initiates you to use drugs?	Depression	13	21.67
	Peer pressure	31	51.67
	To protect hunger	10	16.67
	To protect fear	1	1.67
	*Other	5	8.33

*Other to cope with cold weather and to get strength

Qualitative results

Study participants reported that street children were commonly affected by communicable diseases and substance addiction.

“Street children are mostly affected by communicable disease… they use unclean food from dirty tankers…they complain to have food, money to buy food… Some street children have difficult behavior! They escaped from rehabilitation centers due to cravings from substance addiction like benzene. Families complain their child disobeys their advice. Unwilling to return to their family…. Child-bearing age females mostly use the implant as a result of fearing sexual violence, unprotected sex-related pregnancy. Childbearing age females mostly use implant… of course, there are accidents related trafficking and also raping on the street” (report for 45 years old male participant)

Lived experience of street children

This study pointed out that drug and alcohol abuse is wide spread among street children. One girl stated:

“To cope, I smoke cigarettes, which I believe helps me deal with the stress of living on the streets. My friends and I enjoy drinking alcohol and smoking cigarettes”.

This participant’s actions appeared to be motivated by a desire to enjoy their freedom on the street. The girls in the current study found drinking alcohol and smoking cigarettes, which may have served as a form of escapism from harsh street conditions.

In a similar vein, one ten-year-old girl stated, "I enjoyed "smoking glue," which generates pleasant feelings while also blocking out hunger, cold, and insecurity."

Even more so, a 12-year-old male participant who had recently begun life on the streets spoke of sniffing glue and how it helped him by allowing him to escape the stressors of the street:

“You smoke glue if you don’t want to keep thinking about your situation because it gets you high and makes you hallucinate; you don’t have to keep thinking about living on the streets and all that stuff. I don’t blame anyone who snorts glue; glue alleviates the sadness of living on the streets”.

According to the above narratives, these participants’ lives appear to revolve around drugs. As a result, they exhibit symptoms of substance-related disorders in one way or another.

Factors associated with the health status of the street children

Multivariable logistic regression was done to identify the factors associated with the street children’s health status. With that, the age of the respondents was significantly associated with the health status of the streets. Respondents with the age below 12 and 13–18 were 3.43 times [AOR = 3.43, 95%CI (1.13,10.42)], 3.8 times [AOR = 3.80, 95%CI (1.14,10.47)] more likely to become sick when compared to those who are above the age of 19 years old respectively. Fathers’ educational status was also significantly associated with the health conditions of the streets. Participants’ parents who had no education/were illiterate were 0.37 times [AOR = 0.37,95%CI (0.17,0.84)] less likely to become sick compared to those respondents’ parents who have higher grades completed.

Having work was significantly associated with the health condition of the streets. The odds of being sick among participants who hadn’t worked was 2.12 times that of a participant who had worked [AOR = 2.12, 95%CI (1.12,4.01)].

Similarly, the history of sexual intercourse was also associated with the health conditions of the streets. The odds of being sick among participants who had a history of sexual intercourse was 2.39 times that of a participant who had no history of sexual intercourse [AOR = 2.39, 95%CI (1.06,5.42)] (Table 6).

Table 6

Factors associated with the health status of the streets in Harar, Ethiopia (n = 220).

Variables		Health status
		Sicked	not sicked	AOR (95%CI)
Age	Below 12 years	45	30	3.43(1.13,10.42) *
	13–18 years	80	40	3.8(1.14,10.47) **
	Above 19 years	10	15	1
Gender	Male	106	66	1
	Female	29	19	1.12(0.52,2.45)
Fathers’ education	Illiterate	82	64	0.37(0.17,0.84) *
	Read and write	17	10	0.58(0.19,1.75)
	Highest grade com.	12	35	1
Parents Income	≤ 1,000 ETB	100	63	0.84(0.33,2.14)
	1,001–2,000 ETB	18	12	0.76(0.24,2.36)
	>2,001 ETB	17	10	1
Marital status	Married	55	38	1
	Widowed/divorced	22	10	1.68(0.65, 4.32)
	Not married/died	37	58	1.23(0.63,2.39)
Drug use	No	98	62	1
	Yes	37	23	0.96(0.48,1.89)
Work presence	Yes	56	24	1
	No	79	61	2.12(1.12,4.01) **
Sexual history	No	41	19	1
	Yes	94	66	2.39(1.06,5.42) *

** = significant at <0.01 and

* = significant at ≤0.05, ETB = Ethiopian Birr

Discussion

This study assessed the health status of street children as well as the factors that drove them to live on the streets in Harar, eastern Ethiopia. Furthermore, factors affecting the study participant’s health status were identified.

In this study, less than one-third (18.8%) of the street children were never enrolled in the school. This proportion is lower than that found in an Indian study (66.5%) [20]. The disparity could be attributed to socio-demographic and cultural differences between study areas. Every child is entitled to an education. Even though the Ethiopian constitution guarantees the right of the child to education, some street children do not receive an education due to economic circumstances and other factors [21]. Furthermore, failure to achieve the educational arena leads to street children being endorsed with deviant behavior of the society as they fail to pass through the socialization process which in turn plays a pivotal role in shaping character, attitude, and behavior that is utterly in line with the societal norms and values. Thus, it needs cooperative work from governmental and non-governmental organizations to warranty education for those children.

In this study, the most common factors that enforce street children to live in the street were searching for a job, disagreed with parents, peer pressure, and in search of food (poverty). This is in line with studies conducted in Shashemene town, Ethiopia [22], Nepal [3], and Nekemte Town, Ethiopia [23]. One possible explanation is that the socioeconomic status of study settings is similar. According to the World Bank, neither country is a high-income country [24]. As a result, the concerned body anticipated cascading and organizing multi-sector services, including the creation of job opportunities for addressing the problems of street children, which could benefit and improve the lives of street children [25].

According to the findings of this study, one-third of street children use psychoactive substances. Peer pressure, depression, preventing hunger, preventing fear, coping with cold weather, and growing stronger were the most frequently mentioned reasons by the children. This is consistent with the studies conducted in Ethiopia [22], Nigeria [26], and India [20]. This resemblance could be attributed to the study participants’ shared socio-cultural characteristics. This finding implied that there is a clear gap in the implementation of drug and substance policies, which had a significant impact on the health of street children. Even though our country has policies against drug abuse and punishment for those who sell drugs to minors, drugs are readily available and easily accessed by children. This allows street children to purchase and use psychoactive substances [27].

In this study, the majority of the streets got sick in the past month. This finding was in line with a study done in southeastern Ethiopia [17]. This similarity may be attributed to the similarity in the socioeconomic status of the study participants. This study and other evidence outlined that the means of their livelihood were daily laborers and street vendors. This had an impact on their health and this condition of street children necessitates social intervention to address the present health problems of street children by ensuring sustainable livelihood options among them [25].

This study pointed out that more than one-fourth of the participants had a history of sexual intercourse and among those, one-fifth of them had forced sexual intercourse. The history of sexual intercourse may contribute to poor health conditions of street children. Evidence also showed that interventions that aimed to increase the awareness of those populations should be advocated to help this group of children about the dangers and consequences of unprotected sex, STIs, and HIV infection [27].

Respondents under the age of 12 and 13–18 were 3.43 times [AOR = 3.43, 95% CI (1.13,10.42)] and 3.8 times [AOR = 3.80, 95% CI (1.14,10.47)] more likely to become ill in this study when compared to those over the age of 19. As one gets older, one’s immune system matures and becomes capable of defending the body against potentially harmful agents. The CD4% level decreased until adolescence, then increased in adults, and finally stabilized in the elderly [28].

In this study, the odds of being sick were 2.12 times higher among participants who had not worked than among those who had worked. These findings are consistent with another study that found strong evidence of an association between unemployment and poorer health outcomes.[29]. Unemployment is almost universally a negative experience, and as a result, it is associated with poor outcomes due to the inability to afford health insurance and insufficient funds to eat a balanced diet. Finally, these hurt one’s health.

n this study, the odds of being sick were 2.39 times higher among participants who had a history of sexual intercourse than among those who had no history of sexual intercourse. In fact, most people on the street may engage in unprotected sex, which is dangerous and can lead to a variety of diseases and conditions. In this study, 14.55% of the streets had forced sexual intercourse, and 8.64% had sexual intercourse for financial gain. According to some evidence, unsafe sex is ranked second among the top ten health risk factors in terms of the disease burden it causes. HIV/AIDS, STDs, and unintended pregnancy are just a few of the diseases that can result from unsafe sex [30].

The limitation of the study was the cross-sectional nature of the study (it doesn’t show a cause-effect relationship). The other limitation of the study was the small sample size of the study, non-participatory data collection method, and failure to do reunification of the study participants with their parents. So, we recommend future researchers conduct follow-up studies with larger sample size.

Conclusion

This study identified the factors that forced the street children to resort to the street way of life including looking for a job and disagreeing with parents. Almost all street children drink alcoholic beverages at different frequencies which exposes them to different health problems. One-fourth of the street children had a history of sexual intercourse including forced sex. Those contributed to the poor health status of street children. Furthermore, factors like age, educational status, presence of work/job, and drug use among the respondents were significantly associated with the health status of street children. To improve the lives of the street children active participation of different stakeholders in drawing a roadmap of health and social interventions is very important.

Distribution of sample interviewees by selected sites in the Harar city, eastern Ethiopia, 2021.

(PDF)

Click here for additional data file.

Data collection questionaries.

(PDF)

Click here for additional data file.

The key informant interview guide.

(PDF)

Click here for additional data file.

Street children data used for analysis.

(DTA)

Click here for additional data file.

15 Oct 2021

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Reviewer #1: The research on Health Conditions of Street Children, Their General Life Conditions, and Reasons Forcing to Street Life in Harar, Eastern Ethiopia. Using Mixed Methods, is important in the context of Ethopia. However, I have few suggestions and queries on this manuscript.

Title: Title needs to be rephrased by putting main variables in it.

Abstract: “As it stands now little is known about the extent of the problem including health conditions”. This sentence is unclear, what does it means by “extent of the problem”. In the method you didn’t mention about the type of mixed method used in this study. I don’t see 30 days in February in any year. Please recheck the time duration for data collection. In abstract you are not supposed to write the criteria for the significance level, you can report this in main document. “Overall 220 street children were involved in the study. The most common reason that forced the children to resort to a street way of life is to look a job and quarreled with parents.” These first two lines must be included in the method instead of results. I would suggest you to include both qualitative and quantitative results separately in the result section. In the conclusion, you have reported results, which are redundant to what you have written in result, it is suggested to re write the conclusion of abstract.

Introduction:

The problem was not addressed in a convincing manner. In the introduction section, I couldn’t understand the need to conduct research. It would be better if you explicitly write about the literature, policy, and knowledge gaps in the introduction. In the last paragraph of introduction, authors claim “Now days it is being observed the number of street children is significantly increasing where, a little is known about the extent of the problem including factors leading to being street children and their health status”, without any reference. I also recommend to clearly state the objectives of the study.

Method:

Cross-check the dates of data collection “1-30 February, 2021”. It would be better if you mention the date either in abstract or in methodology, avoid repetition.

Study Design and population: I couldn’t find any description or rationale of choosing mixed method and which mixed method has been chosen. You need to specify research questions identifying quantitative and qualitative method. No information about the sample for qualitative study is reported in this section.

Sample size determination and sampling procedure

What does it means by “Out of this various sit”?

Please provide the reference that the higher number of street children are present in the areas which you have selected for the study. Provide the rationale for applying qualitative method and selection of sample for the qualitative study.

Data collection methods and data collection procedure:

Provide the name of the questionnaires used for the quantitative data collection. If you adapted, then explain the steps/ models used to adapt or contextualize the questionnaire. Also report the reliability and validity of the questionnaires. For qualitative study explain what type of interview guideline was developed and why (e.g., structured, semi-structured, or unstructured). Please share few questions from the interview guideline.

In an article you do not need to provide operational definition however, you can provide the rationale for using specific variables through literature in introduction section.

Data Analysis

What is KII??

Explain triangulation in this study specifically, what is the purpose of triangulation and how would you analysed it?

Statistical Analysis

You have applied multivariate, but you didn’t mention whether the data met assumptions for the multivariate analysis. For qualitative, explain how you develop themes, what procedure or model you followed for finalizing the main themes.

The verbatims stated are not intact. One sentence of the verbatim is not connected with the other sentence. Detail explanation of the verbatim is required. When you clarify the type of mixed method, you will be able to integrate the information from the two studies. Otherwise, the analysis section seems disorganized. Interpretation of the results are also not clear.

In Table 4 “Health status and substance use among study participants in Harar city, Ethiopia”, you have mentioned about depression, do you really think that street children understand what is depression?

Discussion

Instead of reporting percentages in results and discussion, it would be very helpful for the reader to understand if interpretation of the results along the supporting or refuting by previous literature would be reported.

I would suggest that discussion must be organized by giving; 1. argument from literature and culture context, 2. implication of the study and then 3. limitations.

Reviewer #2: • Title is required to be re-phrased.

• Table 1: Under father’s educational status, it is mentioned that around 21% of the children have fathers with education level “highest grade completed”. This category needs to be defined clearly.

• Line 226-232: No need to report frequency since percentages are already given.

• A thorough spellings and grammar check is required for the entire manuscript.

• This paper can be substantially improved by adding more information from the focused group discussions. Qualitative part of the study needs more attention of the authors.

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Reviewer #1: Yes: Siddrah Irfan

Reviewer #2: No

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27 Nov 2021

Title: Health Status of Street Children and Reasons for Being Forced to Live on the Streets in Harar, Eastern Ethiopia. Using Mixed Methods

Manuscript ID: PONE-D-21-13888

From: Authors

To: The editor in chief, PLOS ONE

Version: I

Data: 25/11/2021

Subject: Revision of the manuscript

We appreciate the reviewers' detailed and comprehensive comments. We found the comments to be very helpful, and we appreciate the time and thought that each person put into their constructive comments. We are well aware of the time ,commitment required to provide good reviews and applaud the reviewers for their efforts. We thoroughly revised the paper and responded in detail to the reviewers' questions and comments.The point-by-point description of the changes is provided below.

For editors

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response 1: thank you for your comment. Now the revised version is edited based on PLOS ONE's style requirements.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the original language is written in non-Latin characters, for example, Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible."

Response 2: Thank you very much. We have now added more information about the survey.

3. Please state whether you validated the questionnaire before testing on study participants. Please provide details regarding the validation group within the methods section."

Response 3: Thank you for your input. It has been corrected and is now part of the revised document.

4. Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously."

Response 4: Thank you. We now include it as an addendum.

5. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Response 5: Thank you for your input. It has been corrected and is now part of the revised document. Consent was obtained from the minors' parents or guardians..

6. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available.

Response 6: Thank you for your comment. It is corrected and incorporated into the revised document.

7. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Response 7: Thank you for your comment. It is corrected and incorporated into the revised document. Ethics statement was omitted from declaration section.

8. Please include a separate caption for each figure in your manuscript

Response 8: We are intrigued by your comment, and we accept it; it has been corrected and incorporated into the revised document.

For reviewer 1

Comment 1. The research on Health Conditions of Street Children, Their General Life Conditions, and Reasons Forcing to Street Life in Harar, Eastern Ethiopia. Using Mixed Methods is important in the context of Ethiopia. However, I have a few suggestions and queries on this manuscript

Response 1: thank you for your comment. The significance of this study in the context of Ethiopia is obvious for a variety of reasons, which are briefly discussed below. I believe it is critical because numerous factors lead a person to leave his or her home and join the life of a street person. It is critical because not everyone in Ethiopia lives on the street; if that were the case, we would not need to study because everyone was affected by these serious issues. So, to mitigate the problems and devise solutions that will undoubtedly address a long-standing issue, this research is crucial.

Comment 2. Title: The title needs to be rephrased by putting main variables in it.

Response 2: thank you for your nice comment. It is corrected as the Health Status of Street Children and Reasons for Being Forced to Live on the Streets in Harar, Eastern Ethiopia. Using Mixed Methods.

Comment 3. “As it stands now little is known about the extent of the problem including health conditions”. This sentence is unclear, what does it mean by “extent of the problem”.

Response 3: thank you for your comment and questions. When we talk about the extent of the problem, we're referring to the prevalence of Streetism, which includes health conditions. This sentence can be paraphrased as “Currently, little is known about the prevalence of the Streetism, including health conditions.

Comment 4. In the method, you didn’t mention the type of mixed method used in this study.

Response 4: We are intrigued by your comment, and we accept it; it has been corrected and incorporated into the revised document. The study designs were quantitative cross-sectional studies and qualitative phenomenological studies.

Comment 5. I don’t see 30 days in February in any year. Please recheck the time duration for data collection

Response 5: Thank you for your comment and question. We apologize for such kind of error. Now it is corrected and incorporated in the revised manuscript.

Comment 6. In the abstract you are not supposed to write the criteria for the significance level, you can report this in the main document

Response 6: Thank you for your comment and suggestion. It is corrected and incorporated in the revised manuscript.

Comment 7. Overall, 220 street children were involved in the study. The most common reason that forced the children to resort to a street way of life is to look for a job and quarreled with parents.” These first two lines must be included in the method instead of results.

Response 7: Thank you for your insightful and wonderful comment. We accept your comment and we incorporate it into the revised manuscript.

Comment 8. I would suggest you include both qualitative and quantitative results separately in the result section.

Response 8: Thank you for your comment. We accept it and corrected it in the revised manuscript.

Comment 9. In the conclusion, you have reported results, which are redundant to what you have written in the result, it is suggested to rewrite the conclusion of the abstract.

Response 9: Thank you for your specific comment. We accept it and corrected it in the revised manuscript.

Comment 10. The problem was not addressed convincingly. In the introduction section, I couldn’t understand the need to conduct research. It would be better if you explicitly write about the literature, policy, and knowledge gaps in the introduction.

Response 10. Thank you for your insightful comment. We revised the introduction section based on your recommendations.

Comment 11. In the last paragraph of the introduction, the authors claim “Nowadays it is being observed the number of street children is significantly increasing were, a little is known about the extent of the problem including factors leading to being street children and their health status”, without any reference.

Response 11. Thank you for your specific comment. We revised the citation. Now it is cited and a change was made in the revised manuscript.

Comment 12. I also recommend stating the objectives of the study.

Response 12. Thank you for your wonderful and eye-catching comments. We accept it and revise accordingly.

Comment 13. Cross-check the dates of data collection “1-30 February 2021”.

Response 13: Thanks for your eagle eyes we are already changed it

Comment 14. It would be better if you mention the date either in the abstract or in methodology, avoiding repetition.

Response 14: thank you for your insightful suggestion. Now the revised version is edited and corrected.

Comment 15: I couldn’t find any description or rationale for choosing a mixed-method and which mixed method has been chosen.

Response 15: thank you for your comment. Bringing together qualitative and quantitative research and data in a single study. Mixed-method research is a hybrid that emerged from the most appropriate combination of quantitative and qualitative research methods for a research project. It aimed to maximize the strengths and minimize the weaknesses of the two research methods, increasing the validity of research findings and providing other benefits. As a result, we attempted to use qualitative and quantitative research methods to improve the validity and credibility of the results in particular, as well as the overall research in general. To elaborate further, we employ a qualitative study design based on the Phenomenological approach that aims to develop a complete, accurate, clear, and articulate description and understanding of a particular human experience or experiential moment (Schacht, 1972).

Comment 16: You need to specify research questions identifying quantitative and qualitative methods.

Response 16: thank you for your comment. It is corrected and incorporated in the revised manuscript.

Comment 17: No information about the sample for the qualitative study is reported in this section.

Response 17: Thank you for your comment. The sample size was determined based on the level of information saturation and the variety of ideas among the sub-groups. Data saturation involves sampling until no new information is obtained and redundancy is achieved. We conducted twelve focus group discussions (FGDs) with six participants from various groups and 6 key informants.

Comment 18: What does it mean by “Out of this various sit”?

Response 18: Thank you for your question and comment. This means that of the seven areas mentioned... we attempted to paraphrase the sentences containing this phrase as follows. Street children can be found in a variety of locations throughout Harar. Seven are chosen on purpose because there is a higher concentration of street children in these areas of town known as Arategna, Ajip, Canal, Botte, Shewa ber, Feres Megala, and Andegan Menged. This was accomplished through observation and consultation with key informants working with street children.

Comment 19: Please provide the reference that the higher number of street children are present in the areas which you have selected for the study.

Response 19: Thank you for your comment. This was the data source obtained from the social affairs office

Table 1: Distribution of sample interviewees by selected sites in the Harar city

S. No Name of the Sub town Total of the registered population Number of the interviewees

1 Arategna 50 23

2 Agip 61 28

3 Canal 53 24

4 Bote 92 42

5 Shewa Ber 101 46

6 Andegan Menged 99 44

7 Feres megala 46 21

Total 502 228

Comment 20: Provide the rationale for applying the qualitative method and selection of sample for the qualitative study.

Response 20: Thank you for your comment and suggestion. There are plenty of rationale for applying the qualitative method. To mention a few of them, to obtain more in-depth information on cases (subjective), to validate and confirm the information gathered, and to increase the validity of research findings. It is useful in establishing meaningful relationships between the researcher and ordinary people, which allows for a better understanding of their world and interpretation of the results in terms of a qualitative approach. So, an attempt was made to apply qualitative methods to study these vulnerable groups. Regarding the selection of the sample, participants were selected based on criteria based purposive sampling to get important information from lived experience.

Comment 21: Provide the name of the questionnaires used for the quantitative data collection. If you adapted, then explain the steps/ models used to adapt or contextualize the questionnaire.

Response 21: Dear Reviewer, when adapting the questioners, we kept three things in mind: Language, Pretesting, and the specific question that will be modified

Steps one: We translated it while keeping the purpose of the questionnaire and the intent of the questions in mind. It was done by group members who speak both languages fluently translate it. To ensure the translation's accuracy, the questionnaire was translated back into English by someone who had not seen the original version and was unfamiliar with the questionnaire's context. The back-translated version is then compared to the original, and any meaning differences are corrected.

Step two: To ensure a cross-validity we tried to interview a set of respondents in English and another set in the local language such as Afaan Oromo and Amharic, their answers were then compared to detect differences in understanding.

Step three: Pretesting: The goals of pre-testing are well known: to identify questions that are poorly understood, ambiguous, or elicit hostile or other undesirable responses. We attempted to conduct a pretest using the already-translated questionnaire. We tried to implement all the steps in pretesting such as obtaining an evaluation of a questionnaire and testing the revised questionnaire through its paces on friends, colleagues, and so on.

Comment 22: Also report the reliability and validity of the questionnaires.

Response 22: When choosing a survey instrument, reliability and validity must be taken into account. The consistency with which an instrument produces the same results across multiple trials are referred to as its reliability. The degree to which an instrument measures what it was designed to measure is known as its validity. Statistically, we performed Cronbach's Alpha, which is a measure used to assess the quality of our employed instruments. The result was 0.87, which was within acceptable ranges.

Comment 23: For qualitative study explain what type of interview guideline was developed and why (e.g., structured, semi-structured, or unstructured). Please share a few questions from the interview guideline.

Response 23: Thank you for your comment. In our study, a semi-structured interview guideline was used. Dear reviewers, in response to your humble request, please find below a few questions from the interview guideline.

�  What relationship does your organization/office have with the children of the street?

�  To what extent is the government concerned about the situation of the street children?

�  What are the main problems that they face?

�  What services that your office currently offering to the street children?

Comment 24: In an article, you do not need to provide an operational definition however, you can provide the rationale for using specific variables through literature in the introduction section.

Response 24: Dear reviewer, we gratefully received your constructive suggestion and omitted it (operational definition) from an article.

Comment 25: What is KII??

Response 25: Dear reviewers, please accept our apologies for such a clumsy error when we say KII we mean key informant interview!!

Comment 26: Explain triangulation in this study specifically, what is the purpose of triangulation and how would you have analyzed it?

Response 26: Dear Respected Reviewer, as we all know, triangulation is a well-known technique for increasing the credibility and validity of research findings. Triangulation is a research study can help to ensure that fundamental biases caused by the use of a single method or observer are overcome by combining theories, methods, or observers. In our study, we attempted to use this robust method to improve the trustworthiness and accuracy of our findings. As a result, methodological (both qualitative and quantitative methods) and data triangulation (from different sources using different data collection methods) were carried out to improve the credibility and validity of the research findings

Comment 27: You have applied multivariate, but you didn’t mention whether the data met assumptions for the multivariate analysis.

Response 27: Thank you for your constructive comment. Dear reviewer, before performing a multivariate regression analysis, we verified that all assumptions and data met the criteria, such as

• The relationship between independent variables and dependent variables was linear (which was checked by producing the scatter plots)

• There was no multicollinearity in our data (on collinearity diagnosis we tried to see VIF standard error and Tolerance score)

• Values of the residuals were found normality distributed (Tested by looking at P-P plots from the model)

• A variance of the residuals was found constant (which was checked by producing the scatter plots)

• No influential cases were biasing our models (checked by looking at Cooks distance)

Comment 28: For qualitative, explain how you develop themes, what procedure or model you followed for finalizing the main themes.

Response 28: thank you for your comment. We follow the inductive thematic analysis procedures. First deeply read and read again and again. Then we code the ideas. Then we categorize similar ideas and then it was developed into their thematic areas. To do this we carefully examine the data to identify common themes – topics, ideas, and meaning patterns that appear repeatedly. To finalize the main themes, we followed the procedures such as familiarization, coding, generating themes, reviewing themes, defining and naming them, and writing up.

Comment 29: The verbatims stated are not intact. One sentence of the verbatim is not connected with the other sentence. Detail explanation of the verbatim is required.

Response 29: Thank you for your comment and suggestion. It is corrected and incorporated in the revised manuscript.

Comment 30: When you clarify the type of mixed-method, you will be able to integrate the information from the two studies. Otherwise, the analysis section seems disorganized. Interpretation of the results is also not clear.

Response 30: Thank you for your comment. It is corrected and incorporated into the revised manuscript.

Comment 31: In Table 4 “Health status and substance use among study participants in Harar city, Ethiopia”, you have mentioned depression, do you think that street children understand what is depression?

Response 31: Dear Reviewer, yes, they have no idea what depression entails. We asked them in their native language about depression; they had no idea about the scientific terms or nomenclatures of depression that here we used to report to the scientific world.

Comment 32: Instead of reporting percentages in results and discussion, it would be very helpful for the reader to understand if the interpretation of the results along the supporting or refuting by previous literature would be reported

Response 32: Thank you for your comment. Now it is modified based on the comment provided.

Comment 33: I would suggest that discussion must be organized by giving; 1. argument from literature and culture context, 2. implication of the study, and then 3. limitations.

Response 33: Thank you for your comment. It is corrected and incorporated in the revised manuscript.

For reviewer 2

Comment 1. The title is required to be re-phrased

Response 1. Thank you for your specific comment. It is corrected and incorporated into the revised manuscript.

Comment 2. Table 1: Under father’s educational status, it is mentioned that around 21% of the children have fathers with education level “highest grade completed”. This category needs to be defined clearly.

Response 2. thank you for your specific comment. We accepted the comment and it is corrected in the revised document. According to our study, this is to mean that from grade secondary level (8-10) to preparatory level (10-12)

Comment 3. Line 226-232: No need to report frequency since percentages are already given.

Response 3. Thank you for your nice comment. We incorporate comments in the revised manuscript.

Comment 4. A thorough spelling and grammar check is required for the entire manuscript.

Response 4. Thank you for this comment. It is corrected and incorporated in the revised manuscript.

Comment 5. This paper can be substantially improved by adding more information from the focused group discussions. The qualitative part of the study needs more attention from the authors.

Response 5. Thank you for your insight full comment. It is corrected on the revised document.

Thank you

Submitted filename: Response to reviwers.docx

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20 Dec 2021

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Faisal Abbas, PhD

Academic Editor

PLOS ONE

Additional Editor Comments:

Major Revisions.

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Comments to the Author

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Health status of street children and reasons for being forced to live on the streets in Harar, Eastern Ethiopia. Using mixed methods

This research is important in the context of Ethopia and much needed in current scenario. What and how this research adds in the literature and help policy maker to work for the betterment of street children. I can see improvement in the manuscript, but I have few comments and suggestion for your manuscript, which are as follows:

Abstract

1. Introduction is well written

2. In Method section, you need to report type of mixed method (e.g., sequential or parallel). I have few questions about phenomenological design (See method section).I want to know the reason for conducting interview for quantitative research design and for qualitative you have done focus group. There is no need to mention softwares in abstract.

3. Results: You didn’t mention result heading. For abstract you can explain results by integrating findings of quantitative and qualitative results.

4. Conclusion is good.

Main Manuscript

Introduction:

You have explained the problem in the introduction, but you can add literature from the similar context or from the courtiers which have similar culture and context, to explain causes that force street children to stay on streets.

Material and Method

1. Study setting, and period is explained quite well

2. Explain type of mixed method design. In case of phenomenological study, you need to explain the lived experience. What experience you are studying and how.

3. Sample size determination is fine for quantitative study but for qualitative specially for phenomenological studies the sample size needs to be selected carefully.

4. You didn’t mention name of questionnaires or scales for the quantitative study. Which instrument you adapted. You also have to mention questions of the interview guideline for the focus group.

Results:

This section is quite improved; however, I couldn’t understand the integration point for both qualitative and quantitative studies. Specially, if you are reporting that you did phenomenological study, you need to report lived experiences of the street children.

Discussion

This study has rich data on health status of street children that need to be explained and interpreted in detail. There is multiple limitation for the study that you need to report. You need to explain the future recommendation as well.

Reviewer #2: (No Response)

**********

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Reviewer #1: Yes: Siddrah Irfan

Reviewer #2: No

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2 Feb 2022

Authors’ Response to Reviewers’ comments and Suggestions

Manuscript ID: PONE-D-21-13888

Journal: PLOS ONE

From: Authors

To: The editor in chief, PLOS ONE

Version: II

Data: 21/12/2021

Dear Reviewers

Thank you so much for giving us an opportunity to submit a revised draft of our manuscript entitled “Health Status of Street Children and Reasons for Being Forced to Live on the Streets in Harar, Eastern Ethiopia. Using Mixed Methods to this highly visible impact factor and peer-reviewed Journal. We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript. We are very grateful for the insightful comments and valuable improvements to our premature paper. We have incorporated most of the suggestions and comments made by the handling editor and reviewers. All comments and suggestions are clearly stated and well addressed (a point-by-point to the reviewer’s comments and concerns). These changes are highlighted in Bright Green color within the clean revised manuscript.

Authors’ Response to Reviewer 1’s Comments and Suggestions

Title: Health Status of Street Children and Reasons for Being Forced to Live on the Streets in Harar, Eastern Ethiopia. Using Mixed Methods

To: Reviewer 1

From: Addis Eyeberu (Corresponding Author)

Subject: Submission of Incorporated Comments and Suggestions

First and foremost, we would like to thank you for your constructive and valuable comments and helpful suggestions that helped us to improve and enrich our premature manuscript. Here is the table we have pointed out how authors incorporated your valuable comments, suggestions, and concerns one by one.

Reviewer’s Comments to the Authors Authors’ Responses to Reviewer’s comments

Reviewer’s General Comments Overall, thank you very much for your positive and constructive suggestions

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict-of-interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response) Thank you very much for your valuable inputs in advancing this manuscript. Now we tried to address all comments and it is incorporated in the revised manuscript.

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: No Thank you very much!! Now we have tried our best to utilize the comments and suggestions to make the manuscript technically sound and the data support the conclusion.

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No Thank you so much. We would like to thank you for your inputs and constructive suggestion. Now, we enriched and revised the paper after initial submission.

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes Thanks!

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: No Thank you very much for such valuable intellectual input. The reviewer is correct. The authors critically considered this input. Now, we thoroughly revised and edited the whole parts of our manuscript and extensively corrected all copy-editing errors in the clean revised manuscript. The authors also sent the manuscript to a language expert/editor who critically reviewed, edited, and corrected all language-related errors made in a submitted manuscript.

6. Specific Review’s Comments to the Authors Authors Responses to Reviewers’ Specific comments

# Reviewer 1. What and how this research adds to the literature and help policymaker work for the betterment of street children. Thank you for your insightful questions about how this research adds to existing literature and what it means for policymakers. This, I believe, is a critical question that must be addressed because it is both the core and the yolk of research's ultimate finding.

This study's findings have a significant and profound impact on the existing literature in one way or another. Here are just a few instances from a long list.

o Despite being a pocket study, this study attempted to point out the health status of street children. Because they are vulnerable groups or segments of our population, they have received some attention. As a result, we humbly believe that we are in a position to add this small droplet to the vast ocean of previously acquired knowledge.

o We also endeavored to demonstrate why street children are forced to live on the streets. Only studying the health status of our target population is insufficient; as we found them on the street, we need to find out what factors compelled them to leave their home and live on the street.

o This study also demonstrates how common divorce was among the parents of street children, which was a previously understudied area. As a result, we attempted to see this and demonstrate how prevalent the problem is.

This research finding could play a critical role in improving the lives of street children for policymakers in some way. to name a few.

o Policymakers must take steps toward reuniting street children with their families. For any child longing to be reunited with his or her family, the emotional and psychological hurdles can be enormous. This is especially true for children who have been reintegrated into their families and communities after spending time on the streets as a result of a variety of issues such as family breakdown, parent death, and poverty. As a result, this study throws at least one stone in the direction of changing the current situation.

o By identifying the causes of streetism, policymakers can intervene on the factors that push children to become street children. Poverty, a lack of education, abuse, and a lack of parental care all contribute to the plight of street children. Push-factors such as abuse, domestic violence, or dysfunctional family relationships are common among street children. It may even come to the point where their situation at home becomes unbearable and they choose to live on the street. Therefore, as preventative work reduces the number of children living on the street, organizations must make significant efforts early on.

o To curb the phenomenon of street children, policymakers should take steps to socialize this vulnerable segment of our society. This study plays an important role in this regard.

o This study assists policymakers in working on the education of street children, allowing those vulnerable segments of the population to shape character, attitude, and behavior that is completely consistent with societal norms and values.

o It enables policymakers to devise alternative solutions for street children on how to live their lives in ways other than engaging in criminal activity.

o This study appears to assist policymakers in taking action on substance use among street children, which leads to widespread problems for them.

2. You need to report the type of mixed method (e.g., sequential or parallel). Thank you very much for your countless effort to review our premature manuscript. Now we revised the manuscript based on the comment and suggestions. The comment is incorporated in the revised manuscript.

3.“I want to know the reason for conducting an interview for quantitative research design and for qualitative you have done focus group. Dear, Reviewer, thank you very much for your countless effort. Dear respected reviewer, to be clear from the very outset, we used interviewer-administered questionnaires to collect quantitative data about the participants, while focus group discussions and key informants were used to collect qualitative data. And we have a plenty of reasons for conducting interviewer-administered questionnaires for quantitative research designs, and focus groups for qualitative research designs. We attempted to see and elaborate separately in the sections that follow.

Reason why we undertook Focus group discussion for qualitative research design

o In order to gather information in a short period of time

o To uncover participants' perceptions and values about the problem at hand (Health status of street children and reasons forced them to live on the street)

o So as to dig out and obtain multiple perspectives on the same topic

o To collect data on collective opinions.

Collecting information from carefully chosen groups of people

4. There is no need to mention software in the abstract. Thank you so much for your valuable and insightful comments. It is corrected and incorporated in the revised manuscript.

5. You didn’t mention the result heading. For abstract, you can explain results by integrating findings of quantitative and qualitative results. Thank you for your comment and question. We apologize for such kinds of errors. Now it is corrected and incorporated in the revised manuscript.

6. You have explained the problem in the introduction, but you can add literature from a similar context or from the courtiers which have similar culture and context, to explain causes that force street children to stay on the streets. Thank you for your comment and suggestion. It is corrected and incorporated in the revised manuscript. Now the introduction is revised based on the comments and suggestions.

7. Explain the type of mixed-method design. In the case of phenomenological study, you need to explain the lived experience. What experience you are studying and how.

Thank you for your insightful and wonderful comment. We accept your comment and we incorporate it into the revised manuscript. Since we conduct FGD, their lived experiences were studied and we incorporated the results in the revised manuscript.

8. Sample size determination is fine for quantitative study but for qualitative especially for phenomenological studies, the sample size needs to be selected carefully.

Thank you for your comment. We accept it and corrected it in the revised manuscript.

9. You didn’t mention the name of questionnaires or scales for the quantitative study. Which instrument you adapted. You also have to mention questions of the interview guideline for the focus group.

Thank you for your specific comment. Since we adapted and modified the questionaries from different kinds of literature into the local context, it doesn’t have a specific name however it is a semi-structured questionary. For FGD the sample questions include

Focus group discussion items

1. What do you think are the major causes of child Streetism?

2. Can you give details of the difficulties that street children face?

3. can you give details of coping mechanisms of street livelihood?

4. What do you think the multiple agencies should do to help street children?

5. Do you believe the intervention of the agencies dealing with street children and their families is adequate? if not what do you recommend as an improvement

10. Result: This section is quite improved; however, I couldn’t understand the integration point for both qualitative and quantitative studies. Especially, if you are reporting that you did a phenomenological study, you need to report lived experiences of the street children.

Thank you for your insightful comment. We revised the result section based on your recommendations.

11. Discussion: This study has rich data on the health status of street children that need to be explained and interpreted in detail. There are multiple limitations to the study that you need to report. You need to explain the future recommendation as well.

Thank you for your specific comment. We revised the discussion. Now it is corrected and incorporated in the revised manuscript.

End of authors responses for Reviewer 1

Authors’ Response to Reviewer 2’s Comments and Suggestions

Reviewer’s General Comments Overall, thank you very much for your positive and constructive suggestions

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict-of-interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Thank you very much for your valuable inputs in advancing this manuscript.

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes Thank you very much!!

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes Thank you so much. We would like to thank you for your appreciation and constructive suggestion.

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes Thanks!

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes Thank you very much for such valuable intellectual input.

End of authors responses for Reviewer 2

Submitted filename: Response to reviwers.docx

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23 Feb 2022

Submitted filename: Third revision.docx

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28 Feb 2022

Authors’ Response to Reviewers’ comments and Suggestions

Manuscript ID: PONE-D-21-13888

Journal: PLOS ONE

From: Authors

To: The editor in chief, PLOS ONE

Version: III

Date: 26/2/2022

Dear Reviewers

Thank you so much for allowing us to submit a third revised draft of our manuscript entitled “Health Status of Street Children and Reasons for Being Forced to Live on the Streets in Harar, Eastern Ethiopia. Using Mixed Methods to this highly visible impact factor and peer-reviewed Journal. We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript. We are very grateful for the insightful comments and valuable improvements to our premature paper. We have incorporated most of the suggestions and comments made by the handling editor and reviewers. All comments and suggestions are clearly stated and well addressed (a point-by-point to the reviewer’s comments and concerns). These changes are highlighted in Bright Green color within the clean revised manuscript.

Authors’ Response to Editors and Reviewer 1’s Comments and Suggestions

Title: Health Status of Street Children and Reasons for Being Forced to Live on the Streets in Harar, Eastern Ethiopia. Using Mixed Methods

To: Editor and Reviewer 1

From: Addis Eyeberu (Corresponding Author)

Subject: Submission of Incorporated Comments and Suggestions

First and foremost, we would like to thank you for your constructive and valuable comments and helpful suggestions that helped us to improve and enrich our premature manuscript. Here is the table we have pointed out how authors incorporated your valuable comments, suggestions, and concerns one by one.

Editors comment to Authors Authors’ Responses to Editor’s comments

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Thank you for your comment. Now the authors reviewed the references list. The reference lists were revised to make them complete and correct based on your recommendation and journal requirement. No article has been retracted.

End of editor’s comment

Reviewer’s Comments to the Authors Authors’ Responses to Reviewer’s comments

Reviewer’s General Comments Overall, thank you very much for your positive and constructive suggestions

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict-of-interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed Thank you very much again for your valuable and wonderful input in advancing this manuscript.

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly Thank you very much!! Now we have tried our best to utilize the comments and suggestions to make the manuscript technically sound and the data support the conclusion.

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No Response Thank you so much. We would like to thank you for your input and constructive suggestion. Now, we enriched and revised the paper based on your constructive input.

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: No Response Thanks! we provide all necessary data to the journal and we made all data underlying the findings in their manuscript fully available.

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes Thank you very much for such valuable intellectual input.

6. Specific Review’s Comments to the Authors Authors' Responses to Reviewers’ Specific comments

# Reviewer 1. Please double-check the language and typing mistakes in the article. Thank you for your insightful comments. Now the authors checked the language and typing errors. The authors critically considered this input. Now, we thoroughly revised and edited the whole parts of our manuscript and extensively corrected all copy-editing errors in the clean revised manuscript. The authors also sent the manuscript to a language expert/editor who critically reviewed, edited, and corrected all language-related errors made in a submitted manuscript.

2. Mention the name of the questionnaire you adapted and translated (Afan Oromo, and Amharic) Thank you very much for your countless effort to review our manuscript. Now we revised the manuscript based on the comments and suggestions. The comments are incorporated in the revised manuscript. We tried to do our best to adapt a tool named “the health status of street children survey” from measure evaluation which was funded by USAID and undertaken with the title of “children in Adverse Situations Indicators and Survey Tools”, available at https://www.measureevaluation.org/resources/publications/tl-19-35e.html and from previous studies (BSS tool), which was done by Demelash Habtamu, Addisie Adamu, titled with "Assessment of Sexual and Reproductive Health Status of Street Children in Addis Ababa", Journal of Sexually Transmitted Diseases, vol. 2013, Article ID 524076, 20 pages, 2013. https://doi.org/10.1155/2013/524076

3. What is the validity and reliability of the original version of (Afan Oromo, and Amharic) Dear reviewer, thank you very much for your countless effort. Dear respected reviewer, we tried to mention the validity and reliability of the original tools (English version) in our first version of comments both on revised documents and response to reviewers. In that time, we considered the whole measure we are expected to do before administering data collection tool to the participants so as to enhance and improve the quality of the study. It is clearly known that, the consistency with which an instrument produces the same results across multiple trials are referred to as its reliability. The degree to which an instrument measures what it was designed to measure is known as its validity. Regarding to the English version of the tool we tried to check the validity and reliability statistically. To this end, we performed Cronbach's Alpha, which is a measure used to assess the quality of our employed instruments. The result was 0.87, which was within acceptable ranges. Nevertheless, we are unable to do statistical test such as Cronbach's Alpha for translated tool since the there is no compatible software that accept both local languages. However, the translated languages were back translated to original version and there was no problem of consistency.

4. Cross check whether in sequential mixed method, you will have to collect data from the same respondents or not and share the reference of mixed-method you have followed. Thank you so much for your valuable and insightful comments.

Dear respected reviewer, here we tried to remained you that during data collection, we followed the steps which was mentioned here in. To this end, we first collected and analyzed the quantitative data and following this we collected and analyzed qualitative data. The purpose was to use qualitative results to assist in explaining and interpreting the findings of a quantitative study. Hence, we used sequential mixed methods which is termed as explanatory sequential mixed methods. This can be done either by re-contacting appropriate members of the original quantitative sample or by drawing a new sample that meets the purposive criteria. The reference we followed was according to Creswell, 2003 and (Ivankova NV, Creswell JW, Stick SL. Using Mixed-Methods Sequential Explanatory Design: From Theory to Practice. Field Methods. 2006;18(1):3-20).

End of authors responses for Reviewer 1

Authors’ Response to Reviewer 2’s Comments and Suggestions

Reviewer’s General Comments Overall, thank you very much for your positive and constructive suggestions

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict-of-interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Thank you very much for your valuable input in advancing this manuscript.

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes Thank you very much!!

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes Thank you so much. We would like to thank you for your appreciation and constructive suggestion.

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes Thanks!

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes Thank you very much for such valuable intellectual input.

End of authors responses for Reviewer 2

Submitted filename: Response to reviwers.docx

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7 Mar 2022

Health status of street children and reasons for being forced to live on the streets in Harar, Eastern Ethiopia. Using mixed methods

PONE-D-21-13888R3

Dear Dr. Eyeberu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Faisal Abbas, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Accept

Reviewers' comments:

9 Mar 2022

PONE-D-21-13888R3

Health status of street children and reasons for being forced to live on the streets in Harar, Eastern Ethiopia. Using mixed methods

Dear Dr. Eyeberu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Academic Editor

PLOS ONE