Introduction

With the growing number of refugees around the world, evaluating the refugees’ health becomes more important in determining the health state of society [1]. An increase in the number of migrant refugees is a global issue that has affected many countries [2]. According to the facts and figures reported by the International Labour Organisation (ILO), around the world, about 218 million children between the ages of 5 and 17 are forced to do some kind of manual work, whether paid or unpaid [3]. In Iran, the number of child labourers is 1,200,000, of whom 35,000 reside in Tehran. This population is increasing with global population growth, migration, and the increasing rate of urbanisation [4–6].

Most of the refugees in Iran are from Afghanistan [2]. Political and economic issues have been raised as the most common causes of Afghan migration to Iran within the past 37 years [7]. The results of a census in 2015 [8] indicated the presence of 1,759,448 formally registered refugees, including 1,583,979 Afghans in Iran. The same source also reported that Tehran was a city with the largest population of formal refugees. At the same time, according to informal statistics, the total number of Afghans in Iran, including unofficially registered refugees, is estimated to be close to three million [9].

The relatively low level of human capital of refugees and the legal restrictions on many Afghans in Tehran have placed them among the lowest classes of society [7]. Sanitation facilities, in turn, can cause many health deficiencies, especially among children. Such families mainly live in slums, and their children tend to work in areas such as subways, warehouses, grocery stores, tailors, supermarkets, farms, and even at home to make goods manually [10]. The increasing rate of child laborer is so high that it has affected both developed and developing societies [11]. The issue of child labor is mainly caused by the parents’ unemployment and poverty in a wide range [12].

According to the latest definitions, children and young people who live and work in the streets are known as child labourers [13]. Work deprives children of their basic rights. Their childhood is gone, and their basic needs such as education, health, and recreation are not met [14–16]. According to the recent definition of Human Rights Watch, street child labourers are under the age of 18. They work and live on the streets in different ways. In fact, these children spend most of the day and night in the street. They are mostly forced to work in the streets or unsafe places to earn a living [17, 18] They are either the breadwinner or work to meet their personal needs [19]. There is sample evidence that the most common reasons for child labourers to live on the streets are poverty and the abusive behaviour of alcoholic parents [20]. A similar report also showed that the parents’ deaths and unhealthy family relationships are among the causes that force child labourers to stay on the street [21]. Meanwhile, working and living outside the home is risky for them. For example, many studies in different countries have shown that the current conditions of child labourers, their jobs, and what makes them end up in the streets include adverse physical, mental, and sexual health consequences and social risks [11, 22–25]. According to a body of research, among the major health issues affecting child labourers are physical injuries, HIV/AIDS, sexually transmitted diseases, sexual and reproductive health disorders, harassment and sexual harassment, drug abuse, and mental problems. Due to extreme poverty and limited access to healthcare and education, child labourers are considered the most vulnerable population in society. They are the victims of violence and are forced to live in the streets, scavenging, begging, and peddling in the nearby slums in polluted environments [19, 26, 27].

Child labour has been linked with significant and long-term health impacts. The results of a study by Banstola et al. showed that half of the children working in brick factories in Nepal had difficulty breathing, and more than half of them suffered from musculoskeletal disorders of grade III BPD with severe pain in the elbows, hands, wrists, knees, ankles, and feet. 60% of the child labourers suffered from insomnia. About 6.7% were involved in smoking, and 21.8% consumed alcohol [28]. The findings reported by Betul and Bilal showed that child labour causes stress, frustration, aggression, and depression among children [29]. The health state of child labourers in another study by Abate et al. in Eastern Ethiopia showed that most participants (92.73%) regularly consumed alcohol. Depression (39.22%) and peer pressure (43.14%) were the most common causes of alcohol consumption [19]. Other similar scientific evidence has shown that in Ethiopia, more than four million children live in very difficult conditions [30, 31]. They are at high risk of sexual and physical abuse [32]. Other evidence indicates that 15.6% of child labourers engage in risky sexual activity and 61.6% face health issues [19, 33].

In recent decades, authorities and researchers in Iran have emphasised the issue of child labourers in the streets [17]. Dealing with the problem of child labourers is of particular importance. First of all, the working issue and child labour, regardless of the facts and figures, are important social matters worthy of attention in society and have many social effects. Second, child labourers are among the most deprived children who do not benefit from the most basic rights. Third, because of their special living conditions, child labourers are faced with many wrong and risky behaviours that not only seriously harm the child but also threaten the health of society and other people. So far, few studies have been conducted on child labourers, and they mostly investigated the underlying causes quantitatively. Less attention has been paid to their health problems from different angles. Also, the challenges of Afghan child labourers, who can be different from other child labourers because they are refugees, have not been investigated so far. Thus, it is essential to conduct qualitative research to access the deep layers of their lives and clarify the basic problems they face. Therefore, the present study aimed to explore the challenges facing Afghan child labourers in Tehran via a qualitative approach.

Methods

Data collection

The participants were initially selected in a purposive sampling (n = 18) and then in a snowball sampling (n = 7). Thus, different areas of Tehran were visited to find Afghan children working in the streets and intersections. They were asked to participate in the study. After each interview, the participants were asked to introduce to the researcher other people they knew and those who met the inclusion criteria to participate in the study.

The data collection method in the present study was a semi-structured interview conducted face-to-face with the participants. The interview questions were formulated after three meetings among the research team members with the consensus of all researchers, each from a different speciality. The research questions were designed by the authors of the article, who have expertise in various fields including sociology, psychology, health education, and others.

The questions were finalised after a pilot phase with four participants (Table 1). Initially, based on a review of previous research studies, the authors of the article collaboratively designed four interview questions for the participants. These questions were then experimentally implemented with four participants who met the inclusion criteria for the study. Subsequently, the interviews were analysed, one question was removed, and three additional questions were added to the interviews. Finally, the interview guide was finalised with six final questions.

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Table 1. Semi-structured interview questions.

https://doi.org/10.1371/journal.pone.0306318.t001

For the male participants, interviews were conducted by a man with a doctorate degree in health education and promotion and familiarity with semi-structured interviews. For female participants, interviews were conducted by a woman with a master’s degree in health education and familiarity with research procedures. In addition to the interview guide questions, other questions were also asked to understand more about the participants’ experiences and obtain more in-depth data. At the beginning of each interview, to establish proper communication and more trust, the researcher provided information about his field of study, job, and role in the research. Then he explained the objectives of the study and the procedure, as well as how to report the findings, and if the participants provided written consent, the interview began. First, some demographic questions were asked, followed by the interview guide questions and other minor questions. Three of the parents did not allow their children to participate in the research at first, but by referring to them again and explaining the research process, their consent was obtained.

Notes were also taken during the interview so that the tone of voice, pronunciation of words, laughter, crying, and pauses of the speech, as well as the physical effects of harassment, could also be recorded during the interview. All the interviews were recorded using the audio recorder device. The time and place of the interviews were determined by the participants. As the participants preferred, most interviews were held in a public place, such as a park or a cultural centre affiliated with the town hall. During the interview, no one else was present except for the researcher and the interviewee. Each interview continued until data saturation was finally achieved with 25 participants.

Results

A total number of 25 Afghan child laborers participated in the present study (Table 2). Also, 3 categories, 13 subcategories and 183 primary codes were extracted from the data analysis (Table 3).

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Table 2. The child laborer participants’ demographic information.

https://doi.org/10.1371/journal.pone.0306318.t002

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Table 3. Codes, sub-categories and categories extracted from interviews with Afghan child laborers.

https://doi.org/10.1371/journal.pone.0306318.t003

Discussion

This research was conducted with the aim of analysing the challenges facing Afghan child labourers in Tehran using a qualitative approach. The findings showed that Afghan child labourers face many psychological, health, and social challenges that threaten their health. An important psychological challenge facing Afghan child labourers was the experience of harassment and abuse, which was consistent with the related body of literature [38, 39]. In a study by Moayad et al., which was conducted in Iran, it was reported that more than 77% of Iranian child labourers had experienced one type of harassment [40], and the rate of harassment could be higher in Afghan children as they were refugees. The experience of sexual abuse among child labourers has been reported in several studies [41, 42]. Since Afghan children are refugees and some Iranians do not hold a positive attitude towards them, they are constantly prone to harassment and abuse, and since most of them are illegally present in Iran, they cannot follow up on this. The victims of harassment or abuse were forced to keep silent and cover up what happened to them, which can cause more harassment and abuse in the future. The presence of violence and abuse can happen to both sexes, but considering the cultural contexts that exist among Iranians and Afghans, it can have more destructive consequences for girls. Therefore, female child labourers usually spent fewer hours in the streets. It is suggested that free counselling courses be held to prevent violence against Afghan child labourers in order to reduce these instances of violence as much as possible. Additionally, these courses should provide training on what actions to take after experiencing violence to minimise the consequences they may face.

Another psychological challenge for Afghan child labourers was having negative feelings, which was consistent with previous studies [43]. Aransiola and Justus (2018), in their study conducted in Brazil, reported that working as a child can lead to depression in adulthood [44]. Afghan child labourers are in very fragile conditions, and they always live with fear and anxiety due to their illegal presence in Iran. The experience of many types of harassment has produced distrust in them, so they can no longer trust anyone. Also, Afghan child labourers compare their lives with other children who enjoy better conditions, and this comparison can eventually cause jealousy or even aggression towards the peers.

High-risk behaviours were another challenge facing Afghan child labourers, which is consistent with the findings of many of the previous studies [28, 45, 46]. Abate et al. reported in some research in Ethiopia that alcohol consumption is a high-risk behaviour among child labourers [19]. Living in poor and dangerous areas causes children to get to know and learn about all kinds of crimes at an early age and sometimes rely on those crimes as a source of income. So, some of them were abused by criminals to buy and sell drugs. Some other child labourers lived in groups under the supervision and even ownership of someone special. They lived as a group in dangerous and crowded areas, sometimes prone to risky sexual behaviours, which can, in the future, make them more susceptible to sexually transmitted diseases such as AIDS and hepatitis. Also, some children experienced stealing things from people, which can be due to a sense of jealousy and hatred towards people of a higher socioeconomic status.

Family detachment was another mental challenge that was new in the present study. Working on the street far from home can damage the relationship between the working child and the parents. It can also reduce parental supervision over them, which can threaten their health and prospects. Also, the decision about how to spend the income they have earned can cause tension in the family, which, if not managed properly, can have bad consequences for the child.

Physical problems comprised another health challenge facing child labourers, which is consistent with Habib et al.’s study conducted among Syrian refugee child labourers in Lebanon [47]. The results of a study conducted in India show that child labourers have many physical problems such as sore eyes, headaches, nausea, diarrhoea, backaches, and skin diseases [48]. Many hours of being in the street in hot and cold seasons without adequate protective clothes, rest, and improper nutrition can cause many physical problems, such as physical weakness, sunburn, skin problems, digestive problems, colds, backaches, sore toes, and so on, which should be treated in children. It is suggested that child labourers undergo periodic medical examinations so that, in the event of any physical problems, they can be referred to a specialist and preventive measures can be taken to mitigate the severity of illnesses.

Another finding of the present research was the children’s inappropriate accommodation, which was a new finding in this study. Refugees usually live on the outskirts of cities and in slums, which can threaten their health. Afghan child labourers’ accommodation was improper and unsafe in two ways. On the one hand, they lived in slums replete with crime, and on the other hand, they lived in tiny houses where many people were forced to live together in small rooms and use a common bathroom, which adversely affected their health. That was why some participants had not taken a bath for a month.

Medical and therapeutic problems were also extracted from the present study, which is consistent with the findings reported by Yoosefi Lebni et al. [49]. Afghan children are deprived of insurance services due to their illegal presence in Iran, and since the medical costs are very high in Iran, they mostly refrain from going to the hospital when they are sick and retreat to self-medication. Also, for fear of being sent back to Afghanistan, they refrain from going to health centres for vaccination, which can cause many problems for their health in the future. Among the other problems facing Afghan children, it was reported that the occasional inappropriate behaviour of the medical staff towards Afghan refugees can affect Afghans willingness to see a doctor. Considering the points mentioned, it is recommended that health insurance be provided for Afghan child labourers so that they can easily access medical facilities.

The health threat was another challenge facing Afghan child labourers. Their health is constantly threatened due to their working conditions. They spend most of the day outdoors, which has consequences. They are less aware of the health protocols. They can hardly receive any health services due to the high costs. They do not follow the health protocols, and this can expose them to COVID-19 and other infections. As mentioned in previous studies, refugees are among the populations at high risk of COVID-19 infection [50–52]. Children who engage in scavenging may get diseases such as hepatitis due to the frequent cuts on their hands. As reported in a work of research by Hosseinpour et al., cuts are one of the most common problems with child labourers [53]. Forceful and high-risk sex can also increase the rate of infection with sexually transmitted diseases. Another study by Foroughi et al. showed that children working in the streets are more susceptible to HIV and hepatitis B and C than the general population [15]. Also, their constant presence in the street exposes them to many accidents, especially car accidents, which can lead to nutritional problems in the long run and even malnutrition. The results of some other studies confirm this issue too. Malnutrition and problems such as vitamin deficiency and anaemia are other problems the child labourers suffer from [45].

Neglected childhood was another problem facing Afghan child labourers. These children spend all their time in the streets and do not have any time to play. Even if they had, due to poverty, they did not have any toys to play with and entertain themselves with. Therefore, it can be concluded that their childhood has ended very soon and they have entered the adult world sooner than they should. This issue is more critical for female children, as some are forced to get married at a very young age. Most of these marriages happen by force and for financial reasons. Having a wide age gap with the husband exposes them to sexual harassment and other forms of abuse.

In addition to health-related and psychological problems, Afghan children also faced many social challenges, one of which was dual identity. In fact, most child labourers were born and grew up in Iran and knew nothing about Afghanistan; however, they were still considered refugees and had not been able to fully integrate into Iranian society. This issue created a kind of dual identity. They did not know whether they really considered themselves Afghan or Iranian. They mostly liked to consider themselves Iranian and tried to speak exactly like Iranians as much as they could so that they were not recognised as foreigners. In Iranian society, they were still considered Afghans.

Another challenge facing Afghan child labourers was their educational limitations. In most previous studies, dropping out of school has been reported as a common experience for child labourers [54, 55]. In a study in Indonesia, improving the quality of school service provision can be a solution to the elimination of child labour [56]. Many children were denied education due to the lack of ID certificates and their illegal presence in Iran. Also, the schools for Afghan children were limited in number, and many children refused to go to school due to the distance. Also, the negative attitude of some school principals towards Afghan children was the reason for avoiding the admission of Afghan children to school. Increasing the number of schools dedicated to Afghan children and gradually integrating them with Iranian schools can facilitate the integration of Afghan and Iranian children.

Another social challenge was the lack of sufficient social support. This finding was new to the current study. In Iran, social organisations accountable for child labourers usually do not pay attention to the child labourers of Afghanistan. A limited number of these organisations were supporting Afghan children, and they did not have a coherent plan to promote these children’s health. Previous studies showed that social support for child labourers can increase their self-confidence and cohesion and can prevent violence [57]. Another social problem for Afghan labour children was social isolation. The low-level social skills of child labourers in communication have been reported in previous studies [58]. Most child labourers in Afghanistan had limited social relations, largely due to their inability to communicate due to non-acceptance by Iranians and partly due to their working conditions. They are constantly changing their workplace for fear of arrest by the officers, and because they are not in a fixed place, they cannot make many friends. Another social challenge that Afghan children faced on a daily basis was social humiliation. Although it has been several decades since Afghans immigrated to Iran, they still have not been able to integrate into Iranian society. So many times, Afghan child labourers were insulted in the streets and called abusive names, and they were humiliated very often.

Conclusion

The present findings showed that the child labourers of Afghanistan are facing many mental, health-related, and social challenges. Any attempt to improve their health requires intervention at different levels. At the individual level, it is possible to meet their health needs and make them aware of the dangers of working in the street through regular physical examinations by holding different training workshops such as violence prevention, anger control, prevention of risky behaviours, prevention of infectious diseases such as hepatitis, and strengthening self-confidence. Also, at the social and familial level, interventions can be made by adopting effective policies at the macro level, such as providing accommodation in safer neighbourhoods, health insurance for child labourers, allowing them to study at school, preventing dropouts, and strengthening their social and interpersonal relations to socialise and improve the health of Afghan child labourers. Training programmes and workshops can help with this.

Supporting information