Physical, mental and healthcare issues of children on the street of Ibadan, Nigeria

Background Most street children studied in lower- and middle-income African countries are without family links. However, the majority of street children are children on the street, living with families during the night and spending their day-time on the streets. The health of this majority group is poorly captured in the literature despite the growing epidemic of child streetism. Aim To explore the health of children on the street of Ibadan using multiple qualitative studies. Setting A street in each of the five urban local government areas of Ibadan Oyo State, Nigeria. Methods Participants comprising of children on the street, parental figures, street shop owners and child-welfare officers were purposively selected and interviewed. Interviews were audio recorded, transcribed, and thematically analyzed. Results Using triangulated data from 53 interviews, the study found that the children on the streets of Ibadan experienced many health challenges. Outstanding are poor carbohydrate-based diet, open defaecation with consequent infections, physical injuries and few deaths from road traffic accidents. Sexual, verbal and substance abuse were common although few children acquired resilience to adversity. The children had poor health-seeking behaviour and resorted to patent medicine dealers or tradomedical practitioners on the streets. Conclusion This study bridged some gaps in the literature regarding the health of children on the streets in Nigeria. The straddling of children between the family and street has cumulative health consequences as depicted in this study. Contribution This research can inform family-level intervention and primary health care plans to forestall the health challenges of children on the streets.


Introduction
Children on the street have existing links to their families and constitute 80% -90% of street children, in urban regions of low-and middle-income countries (LMICs), like Nigeria. 1,2,3 These children return home daily to their families regardless of their street activities, unlike other minority groups of street children including children of street families, children of the streets and children who absconded from institutional care. 1,2,3 street is not outstanding. 1,2,3,7,8,9 Health problems of street children include malnutrition, infectious diseases, substance abuse, sexual abuse, injuries, behavioural disorders and a lack of access to health care. 1,2,3,7,8,9 A meta-analysis of African literature revealed the aforementioned morbidities among street children and recognised that most studies were centred on children of the street. 2 Another systematic review revealed that the studies concentrated on minority groups of street children lacking specifics for children on the street. 10 In a health study of street children conducted in Ibadan, Nigeria, although 90% were acknowledged as children on the street, they mostly captured children of the street. 11 The study then recommended dedicated research to explore the health of children on the street who are the major category of street children. 11 Considering that children on the street are the prominent category, the lack of data on their health constitutes a disparity in health research on street children. 1,2,3,7,8,9,12 The 2015 report on 'Children Left Behind in Nigeria' and similar reports recommended targeted research to ameliorate this disparity. 13,14,15 This study explored the health of children on the street of Ibadan, sourcing in-depth information and providing insight on specific health problems.

Theoretical framework
The Bronfenbrenner bio-ecological system theory was used for the conceptualisation of this research. This theory examines the interaction between factors in the immediate family and society that can affect the child's development. 16,17,18 The theory addresses the microsystem, mesosystem, exosystem and macrosystems of a child. 16,17,18 The family is the typical microsystem with the unusual ecological crossing into the streets that are an atypical microsystem, where children mingle with other elements outside the family. 16,17,18 In the exosystem, the child welfare officers are involved with the support and care of these children on the street, and street shop owners witness their livelihood. In describing the health of children on the street, there is a need to evaluate their immediate family and understand the interactions on the street that affect their health and take the perspective of persons in the ecosystems.

Research methods and design Design and sampling
This descriptive cross-sectional study evaluated the everyday conscious understanding of the health experiences of children on the street while setting aside preconceived opinions. 19 This research utilised four qualitative methods including in-depth interviews (IDI) with children on the street, paired IDI with a dyad of a parental figure and a child on the street and IDI with Oyo State's child welfare officers and street shops or business owners. Participants were sampled purposively using the snowball technique from five streets in Ibadan, capital of Oyo State Southwest Nigeria, selecting a street from each of the five urban Local Government Areas (LGAs): North (N), Northwest (NW), Southwest (SW), Northeast (NE) and Ido. The selection of a street in each LGA was guided by information derived from the Oyo State directorate for child welfare services, which provided information on the streets with a known active population of children on the street. Sampling across the five urban LGAs of Ibadan allowed for a detailed description of the phenomenon in Ibadan.

Participants and recruitments
The selection of children on the street was initially purposive as guided by the street shop owners who were familiar with the parental figure and thereafter by snowball technique on each of the streets. The sampling matrix as shown in Table 1 explains the participants' characteristics and selection across each of the five urban LGAs in Ibadan.

Data collection procedure and measures
Ethical approvals were obtained Data were collected between June and September 2021 and universal precautions (including the use of facemasks and hand sanitisers) against coronavirus disease 2019 (COVID-19) were ensured. The research document was written in English language and the Yoruba (local) translation. A back translation of the Yoruba version to English was done to ascertain the literal validity of the original document. Either of the two versions was used based on the language preference of the participants. Ibadan city has a mix of indigenous mostly Yoruba-speaking people and educated people who can converse in English. Written consent and assent were obtained from each participant. The interviews were moderated using a pre-developed interview guide and audio-recorded using a digital recorder. The interview guide was self-developed to explore the pertinent health issues of children on the street referenced in literature and to fill the gaps identified. The interview guide adopted probe questions that had been used by other studies to evaluate the documented health concerns of children on the streets, emphasising on their health status and challenges. 2,4,11 The guide contained questions exploring general health LGAs, local government areas.
problems, problems regarding food and water consumption, toilet habits, mental health-related problems, health hazards on the streets, healthcare-seeking behaviours and options of children on the street.

Data management
Direct and complete transcripts of the audio-recorded interviews were typed out in Microsoft Word. The qualitative data from the 53 interviews were analysed using procedures of framework analysis, including five levels of systematic data processing: familiarisation, identification of thematic framework, indexing, charting and mapping. The data from the four qualitative studies were triangulated 19,20 by converging information from all participants. Coding was done using the Atlas Ti version 8.4, with the generation of specific codes for a robust appreciation of the health issues of children on the streets of Ibadan.

Ethical considerations
Ethical clearance to conduct this study was obtained from the University of Witwatersrand and the Oyo State Ethics Review Committee (No. M210424 and AD 13/479/4118A).

Results
The analysis was organised into three themes: (1) physical health challenges, (2) mental health issues and (3)  These themes emerged through framework analysis of the triangulated data obtained from the children and significant others within their ecosystem. The health conditions were consequent of cumulative factors in the immediate family and the street microsystems. Poor nutrition, depressive feelings, verbal abuse, poor health-seeking behaviours and unconventional healthcare stemmed from factors within the family and are worsened by the children's presence within the atypical street microsystem where they spend most of their daytime. Poor toilet habits, exposure to infections, sexual health problems, injuries with body aches, allergies, misbehaviours, substance abuse and psychological strength were consequences of the unusual ecological crossing into the streets where children mingle with other elements outside the family. Table 2 describes the respondent labelled in the bracket for each quote.

Physical health challenges
The physical health challenges are physical conditions affecting the children on the street due to street elements, some of which are underscored by factors within the family. Six aforementioned subthemes explained these physical health challenges including poor nutrition, poor toilet habits, exposure to infections, sexual health problems, allergies and injuries.

Poor nutrition
Many of the children who were interviewed reported that they were unable to access food in their household and went hungry until they made money from street hawking or their parents received handouts from neighbours. Child welfare officers shared instances: 'The mother leaves early in the morning without providing food for the children and returns home at 11pm, expecting the children to look up to their neighbours for food. The children just find their way to the street.' (WO5, 46, F) A few children shared their stories: 'When we wake up in the morning we do house chores, then whatever little money our parent has, they give us to buy something to eat first, maybe later if they see someone to give them money we will eat properly.' (PC7, 17 Street shop owners and welfare officers mentioned that the children drank from various sources of water, including hygienic ones like pre-packed treated water. It was, however, mentioned that the children drank untreated sachet water and unhygienic ones like stagnated well or rain water when on the street. A few of the children who hawk pure water, that is pre-packed sachet water, reported that they drank from their stock when thirsty. Participants opined that the children buy sachet water, because it is cheap or take water from government boreholes or well water on the street: 'They drink whatever type of water that is available, clean or not, it doesn't matter as long as it quenches their thirst.' (WO3,41, F) 'Presently a constant variable is the unhygienic condition these children found themselves in. There is poor environmental sanitation and a lack of proper waste control on most streets which readily contaminates the food and water they consume, and they get sick.' (WO12, 51, M) Parents and children expressed their fear of children contracting infections and gave examples of instances of illness: 'We have helped people carry loads and used our hands to pick their oranges from the gutters, we carried loads dirtied in mud and disposed of people's waste on our heads, I think that gave me diarrhoea one time.' (PC7,17, M)

Poor toilet habits
'It is God that protects against food contamination and diarrhoea, we eat on the street but as a mother, I know it is not proper and responsible of me to have my child hawking and eating from street canteens which are usually dirty, but it is because of our situation.' (PC, 35,Mother) A few children reported that in their opinion they had contracted genitourinary infections like gonorrhoea through indiscriminate urination in dirty places and child welfare officers recounted similar cases: 'I can "toilet" (defecate or urinate) anywhere, to the extent that I have "toilet disease" many times.' (C8,17, F)

Sexual health problems
Shop owners and child welfare officers passionately shared stories of sexual exploitation, abuse and assault of both boys and girls with consequent teenage pregnancies. Shop owners reported that physically mature girls get sexual advances and harassment from men and reported sexual exploitation between girls and boys on the street: 'It happened to me when I hawked as a child, "area boys" see me and say: "girl how far?" Back then, I took alternative street routes to avoid the area boys.' (*SO7,41, F) 'The girl was at a tender age of eight years. I visited the mother and intervened for her to be taken off the street because she has been sexually abused repeatedly.' (WO3, 41, F) Welfare officers narrated cases of young girls who hawk and have been repeatedly sexually abused by men and shared stories of unwanted teenage pregnancies: 'Girls' population is not much among the children, but unwanted teenage pregnancies are common nowadays. Sometimes ago we went out for raiding children, unfortunately, some girls had positive pregnancies during the routine test we did.' (WO12,51, M) 'A case I handled before, was that of a girl who was repeatedly sexually abused, and nobody took responsibility when it resulted in pregnancy.' (WO5,46, F) Some mothers said that they avoid sending their mature daughters to the street to avoid sexual exploitation. A few shop owners and welfare officers opined that unwanted teenage pregnancies and births contributed to the increasing population of children on the street: 'Ibadan is the worst place; you see all those young girls hawking "pure" [sachet] water with the pregnancy. The boy that impregnated her will be doing "guy" around and still impregnate another girl.' (SO8,28, M)

Aches and injuries
Most of the children complained of headaches that were worse on sunny days and pains affecting the neck and limbs. Some parents attested to these complaints and welfare officers and shop owners shared their awareness. Street shop owners who were previously children on the street narrated lingering body aches and pains dating back to childhood days of intense street hustling activities: Welfare officers reported cases of children on the street who died from swimming when they went to defaecate in streams or decided to take a swim: 'They leave their goods somewhere and go swimming in the streams around for fun and hope to catch fish and hawk it for money, unfortunately, some have drowned and died.' (WO3,41, F) 'There was a situation whereby some children went to the river to swim and drowned recently and two years ago at "Asejire" river.' (WO12,51, M)

Allergies
A few children complained of eye irritation, chest discomfort and cough when on the streets. Some mothers acknowledged that these irritations occurred because their children were exposed to dust and fumes on the streets. Child welfare officers mentioned that allergic conditions were known health problems for these children:

The mental health issues of children on the street
This is the second theme that entailed the mental health problems and strength found among the children on the street. The mental health theme has five subthemes, including depressive feelings, misbehaviours, verbal abuse, substance abuse and psychological strength.

Depressive feeling
A few children said that they occasionally felt ashamed, sad and hopeless when they thought of the situations that brought them to the street or saw other children being cared for by their parents passing by on foot or in cars. Child welfare officers share their concern for future depression in these children, especially those exploited and abused: Street shop owners and welfare officers said the children's misbehaviours reflected their exposure to ill-mannered street thugs or touts: 'Some of them learn how to fight on the street, they easily get angry, and they don't have the habit of saying sorry when they offend someone.' (SO7,41, F)

Verbal abuse
Some children reported verbal abuse from people on the street and described the unfair insults and derogatory remarks from people who patronised them.

Substance abuse
The children and their parental figures denied substance abuse among the selected children, but the shop owners and welfare officers reported that children are lured into substance abuse through their interaction with commercial drivers in garages and members of the National Union of Road Transport Workers (NURTW): 'The smaller children would have been eyeing those smoking out of curiosity, so they eagerly taste. The older children are sent on errands by these street thugs to go and buy Indian hemp, "Oja" that's their language and they eventually start smoking by association.' (WO5,46, F) 'I saw my mates drinking alcohol and I thank God I am not drinking alcohol.' (C7, 15, M) It was reported that children smoke and drink all sorts of things that cause serious intoxication. Reportedly both boys and girls are lured into ingestion of 'health' herbs soaked with alcohol: 'Children assist those selling alcoholic drinks on the street, particularly those who sell herbs soaked with alcohol called "Agbo -jekomo," they are invited to taste it as a health remedy, and little by little they start taking alcohol habitually.' (WO3,41, F) Child welfare officers and shop owners opined that these children were at risk of substance addiction and related longterm mental health problems and they gave examples. Welfare officers reported the challenges of rehabilitation of the children once they got addicted; some skipped school and eventually left home: 'We do see one child that had sold things in traffic on this street before, he has gone mad because he smokes Indian hemp, and he still roams the streets to date.' (SO9,45, F)

Psychological strength
A few child welfare officers opined, that despite tales of woe, hazardous exposures and bad experiences, a minute proportion of children turned out to be mentally strong, vigilant and resilient: 'Most of these children are psychologically strong. They are very determined, so they developed a kind of resistance to the way and situation they have found themselves in.' (WO12,51, M) 'I have "brain" no man can deceive me that he wants to give me five hundred, because I know that when I sell, I can make a gain of five hundred and I have seen results of girls that were deceived.' (C8,17, F) A few past and current children on the street shared that they learnt from the mistakes of their peers and were determined not to fall victim:

Healthcare issues of children on the street
This third theme addressed the healthcare issues of children on the street. Two subthemes emerged including poor health-seeking behaviour and unconventional healthcare options available to the children on the street when they fall ill as a result of engagement with street activities.

Poor health-seeking behaviours
It was reported that the children had poor health-seeking behaviours. Shop owners and child welfare officers said that mothers downplayed these children's illnesses and delayed getting treatment: 'He doesn't use drugs like that, except when he is very sick, he takes after me in that manner, when he has pains, he sleeps it off and wakes up alright.' (PP6, 52, Mother) 'The market women will ask the child "did you not know you were sick before coming out to the street?" and the child usually says, he knows, he just said he should manage to come and hawk.' (SO7, 41, F) Children living with guardians reported that the guardians disregarded their complaints of ill health, so they resorted to taking part of the money made on the streets to obtain drugs at the chemist without the knowledge of the guardian when the illness worsens. A few children said they found a place to nap or rest on the street when sick and thereafter continued their activities without getting any treatment:

Unconventional healthcare
Many respondents said that ill children on the street had limited access to conventional healthcare services and resorted to the available and affordable unorthodox options. A visit to the 'chemist' or 'patent medicine seller' is reportedly a popular option: 'The child goes to the chemist and explains the illness. The chemist won't ask if he or she has eaten or not, they take money from the child and count different kinds of drugs and hand it over. Even when the mother is informed all she does is buy an over-the-counter mixture of pills from a chemist and give the child.' (WO6,54, F) 'I will get drugs by myself at the chemist, I tell the chemist how I feel and they give me whatever drugs I need. Sometimes, I could have remnant drugs at home from the chemist and I use just that.' (C9, 17,M) Street shop owners reported that even when children go home or tell their mothers of their illness, the treatment option includes a visit to the chemist or purchase of pills from roadside drug peddlers. Child welfare officers opined that because the children are minors, they are unable to approach conventional health care providers and opt for herbal concoctions, which are readily accessible and affordable. Welfare officers said that the mothers preferably look for tradomedical practitioners or procure herbal concoctions for the child: 'I use herbal drugs, I buy from herb sellers that hawk around the street, they already know how they sell it to me.' (C10, 17

Physical health challenges of children on the street
Food security is defined based on the availability of adequate food, access to food and appropriate food consumption. 21,22 The children on the street experienced occasional household hunger; they had poor feeding patterns, and carbohydrates were the available staple foods for them in their homes. Specifically, it was deduced that most of the children barely had breakfast daily or ate plain bread, and they bought cheap food that contained mainly carbohydrates when on the street. This research revealed that many of these children lived in a household with inadequate quality and quantity of food that can support their nutritional requirements for proper growth. Food insecurity in Nigeria is associated with the poor earning power of the head of the family, 22 which is relatable in this study. This is because the money generated by the children is needed for the children's breakfast or to support the family's main meal, which is usually dinner. This study revealed that children on the street are from food-insecure families, clearing the impression of a better nutritional status among this category of street children. 10,23,24 Although in this study many of the children drank pre-packed 'sachet' water that is affordable, it is common knowledge in Nigeria and other neighbouring countries that not all 'sachet' water is hygienically produced. 11,25 The tendency for these children on the street of Ibadan to drink 'sachet' and other unclean water with the attendant contamination of food and water due to the unhygienic nature of the street can cause diarrhoeal diseases as found in this research and, published previously, for children living on the street. 26,27 The unhygienic and indiscriminate sanitary habit of children while on the street was extensively reported, while open defaecation featured prominently as similarly published for street-dwelling children in other sub-Saharan African LMICs. 11,28,29 Interestingly, this study found that few children go back home to use the toilet facilities when convenient. Likewise, the inadequate number and fees charged for public toilets in Ibadan have not been extensively published as a reason for the indiscriminate toilet habit of children on the street. The defaecation of children into streams or rivers with the risk of drowning and death was an unexpected finding.
The attendant risk of communicable febrile illnesses like malaria and COVID-19, food and water-related gastrointestinal disease and skin rashes were not exceptional findings in this study. In the background of poor nutrition and the unhygienic nature of the streets in LMICs, children on the street are prone to food, water, insect and air-borne diseases. 10,26 The lack of personal protective devices during a pandemic as observed in this study is another factor that can predispose children on the street to communicable diseases. Street children have been described as invisible and excluded from the health care plan. 12,30,31 This was apparent during the data collection for this study, as despite the COVID-19 pandemic, there were no targeted plans or actions from the health ministry for the protection of children on the street. These children were unperturbed about masking up until convinced by the research team. Related to air-borne disease exposure is the risk of environmental health hazards, like the dust raised by passing vehicles and smoke from exhausts that resulted in irritative allergic symptoms for children in this study. The report on eye and lung allergic reactions among children on the street is insightful and should be a focus for future health research. Although studies had reported inhalation injury among homeless street children and respiratory infection as morbidities among children of the street, there is no mention of allergic respiratory disease. 32,33 Many of the children in this study complained of recurrent injuries, aches and pains, which were attributed to musculoskeletal strains caused by activities on the street, as expected. 10,26 Common causes of physical injuries for children including fights with peers, trauma sustained due to roughness of the street and motor vehicular accidents were reported in this study. 29,33,34 These causes of injuries were reported for the children in this research. Nevertheless, it was reported that boys get injuries inflicted due to physical assault while being financially exploited by unscrupulous motor-garage men. Financial exploitation particularly of the boys on the street had been reported by other African studies. 35,36 However, the fact that the process of financial exploitation by street thugs inflicts physical injuries on the children on the street was an interesting finding in the research. Road traffic injuries (RTI) were featured in this study as expected and a few deaths from RTI were unfortunate incidents. The safety of these children should never be undermined, and understandably interviewed mothers were very concerned about the risk of RTI but seemed incapacitated by their needs for the income generated by these children.
In this study, children hawking goods on their heads complained of neck pain, and former children on the street complained of chronic low back pain, dating to childhood days of hauling loads on the street. These musculoskeletal complaints suggest that neck and back arthropathy should be considered as part of the health challenges of children on the street. Body aches and pains when associated with headaches and malaise could be symptoms of malaria considering their exposure to incessant mosquito bites from stagnant water on the street. 37 A few of the children who reported that they needed to rest and nap somewhere on the street could have had malaria-related aches and pains.
This study found that children on the street of Ibadan were sexually harassed, exploited and abused. A study published that new and younger children were prone to sexual abuse by adults or older boys and girls on the street, contrary to reports from other studies, as opposed to other literature on street children. 36 The sexual exploitation reported in this study was recurrent regardless of gender, age of the children or time of arrival on the street, as opposed to other literature on street children. 37,38,39 In this study, sexual exploitation with consequent teenage pregnancies and refusal to identify or ascertain the perpetrators were reported. Likewise, denial of paternity from men or boys that impregnated the girls was a common event on the streets of Ibadan. Accordingly, Fawole and colleagues published that society may show sympathy for sexually abused girls, but there is an attendant risk of stigma, fear or shame that deter them from reporting the sexual abuse. 40 The study further revealed that street girls who report the abuses are prone to physical assaults by perpetrators and loss of their goods, among other things, and these might be the reasons why girls were reluctant to report sexual abuse to date. Out of concern about sexual exploitation and its consequences, a few mothers in this study preferred not to send their mature daughters to the street, whereas some mothers were unbothered. As was expected, there were few reports of sexually transmitted infections (STIs) among children in this study. 26,37,40 However, the report of children in this study, who had contracted sexually transmitted and urinary tract infections from indiscriminate and unhygienic toilet habits on the street needs future probing.

The mental health of the children
The children in this study reported depressive feelings in the form of shame, sadness and hopelessness associated with their situation. These feelings are related to the reasons for their presence and activities on the street. Published literature on the mental health of street children has reported mood disorders but specifics for children on the street are not obvious as highlighted by this study. 36,41,42 Behavioural problems are documented mental health challenges of other minor categories of street children and there are gaps in the literature regarding behavioural problems among children on the street. 3,43 Therefore, it was enlightening to find children in this study who realised their misbehaviours towards their parents and worked on positive change. Additionally, street shopkeepers in this study had understudied the trajectories of behavioural problems of these children. The shop-keepers described a trajectory that typically began with discourtesy and aggravated to unruliness and aggression.
Verbal abuse from parents at home was a discovery in this study, which occurred when the children were unable to meet the parents' expected sales target on the street. The children had to endure constant cursing and derogatory remarks from people who patronise them and other people who would not patronise but swear at them at the slightest chance. Although studies on the mental health of street children had highlighted general emotional problems mostly in children of the street, verbal emotional abuse was not prominent. 24,33,44,45 The complaint of verbal emotional abuse must not be trivialised, because if it coexists with feelings of shame, sadness and hopelessness it may become a risk for depression and substance abuse among children.
The use and abuse of alcohol and smoking of marijuana (Oja) were reported among children in this study. Although all interviewed children denied substance abuse, some gave examples of their peers involved in this act. The presence of children on the street and exposure to unscrupulous adults, particularly commercial motor-park touts (Agbero) as reported in this study, was concerning. The association of these children with the Agberos constituted a risk for their substance abuse particularly marijuana. 11,35,42,46 A study pointed out the lower prevalence of unprescribed medication and substance abuse when children stay and are cared for at home and are not exposed to street life. 47 Smoking marijuana, alcohol use and abuse are known mental health problems of street children in general. 11,35,42,46 However, this research detailed the manner of indoctrination of children on the street bridging research gaps on substance use among street children.
It was a pleasant surprise that few participants in this study opined that positive mental health attributes can be developed by children. These attributes included resilience and determination to succeed, as previously documented for children of the street. 48,49,50 Although this study did not specifically enquire about the factors that support the positive mental health attributes observed in the children, it was inferred that they learnt from other people's mistakes. Studies have associated resilience in homeless street children with support from non-governmental organisations (NGOs), religious beliefs, meaningful and reciprocal friendships and a sense of humour. 42,49 However, there are many adverse health issues for the child on the street, which outweigh these perceived mental health benefits, as listed in this study and corroborated. 50 This perspective of positive mental attributes gained by the children does not excuse the fact that the street is an unhealthy microsystem for the physical, cognitive and psychosocial development of a child. 36,51 A child raised within a family can be linked to other microsystems like school and other ideal social networks where these positive mental health attributes can be developed and nurtured.

Healthcare challenges
In this study, the children delayed seeking healthcare because they or their mothers trivialised illness symptoms, and at the extreme illness, complaints were ignored by the guardians until it becomes critical. It was reported that one of the reasons for the delay in healthcare seeking is because the mothers lacked knowledge of orthodox healthcare. Eventually, when they did seek healthcare, they preferred unorthodox healthcare due to its accessibility, affordability and alignment with parents' beliefs. A 2008 Indian study revealed similarly that parents and associates of street children, the severity of the illness and the family's financial constraints were obstacles to prompt health-seeking of working street children. 52 Although that study included all working street children and did not delineate the obstacles for children on the street, as found in this study. Another study in Durban reported poor healthseeking behaviours among homeless street children, which were associated with non-existing links to a family, which could render them the needed support to seek prompt healthcare. 50 This study has shown that children on the streets have poor health-seeking behaviour related to socioeconomic factors and the health perception of the family.
Preference for unorthodox and unconventional healthcare is the norm for the children in this study. The patronage of a chemist, street drug vendors and the use of herbal concoctions by children on the street of Ibadan is not a new finding. 37,53 However, what is worrisome is the normalisation of consumption of herbal concoctions and alcohol-based 'health herbs' among these children, which is being vended by women on the street. A study had queried the apparent 'innocent' vending of harmful substances to children on the street by grown women who should be better informed. 35 Therefore, the national monitoring agency for drug administration and child welfare officers needs to regulate sales of health herbs especially alcohol-based ones to street children and increase awareness of the health hazards. Unmonitored patronage of untrained patent drug-store owners on the street because of proximity and affordability exposes the children to consuming mixtures of over-the-counter pills with its attendant acute and chronic systemic health problems.

Strength and limitations
This study, to the best of the authors' knowledge, revealed the realities of health issues of children on the street of Ibadan, Nigeria that have not been explicitly written in literature. In addition, various opinions were sought from divergent stakeholders. However, a limitation is the fact that most of the mentioned infectious diseases could not be substantiated by specific objective assessments and measures.

Implication for further research
Further research on the health issues of children on the street is recommended, incorporating validated quantitative measures that can further substantiate the health problems of these children within the provision of research ethics of vulnerable children.

Conclusion
This study revealed the health issues of children on the street of Ibadan Nigeria using a qualitative approach by sourcing information from the children and significant informants in their ecosystem. The result showed that the health issues identified are more related to their presence on the streets, which is an atypical microsystem for these children. Therefore, family-level interventions are necessary to deter the family-oriented health challenges and control the streetrelated health problems and adverse exposures. For instance, the poor nutrition, mortality related to poor toilet habits and RTI, the luring of children to marijuana and alcohol use by street touts and unrestricted sales of alcohol-infused herbal remedies to children should be curbed.