Chawhanda, Christine2023-07-132023-07-132022https://hdl.handle.net/10539/35654A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, 2022Background Migrant health including sexual and reproductive health (SRH) is an important global public health concern and universal access to SRH services is one of the key milestones towards fulfilling the sustainable development goals. An increase in female international migrants in Africa has been documented between the years 2000 and 2020. Most of these migrants are in the reproductive age group 15- 49 years with the average age of international migrants being 39 years. The migration of people of reproductive age has important implications for public health and in particular, access to and utilisation of SRH services. Literature has shown that globally (including in Southern Africa) there are inequalities in accessing and utilising SRH services between migrants and nonmigrants. Migrants are usually denied access to public health services or are hesitant to access public health facilities due to fear of being deported especially when they do not have legal residence status. Being a migrant has been associated with compromised access to and utilisation of health care, including SRH services. Therefore, the purpose of this study is to investigate the factors associated with access to and utilisation of SRH and HIV services among women in high migration communities. Furthermore, it, explores the experiences and coping strategies of migrant women in accessing and utilising SRH and HIV services as well as experiences and coping strategies of healthcare workers in providing SRH and HIV services to migrant women. Methods A mixed methods study design using both quantitative and qualitative methods was used. Data from a cross sectional survey conducted as part of the SRHR-HIV Knows No Borders Project in 2018, was used for the quantitative component. Logistic regression models were fitted to investigate factors associated with utilisation of sexual and reproductive health services among 2070 women aged 15-49 years in high migrant communities in six Southern African countries. For the qualitative component a phenomenological qualitative design that focuses on detailed exploration of an individual’s lived experience of a phenomenon was used. The study population comprised of internal and international migrant women of reproductive age 18 to 49 years and healthcare workers who provide SRH and HIV services. Snowball sampling was used to recruit migrant women while healthcare workers were purposively sampled. In-depth interviews with five internal migrants, eight international migrants and four healthcare workers were conducted from December 2019 to March 2020. Thematic analyses were carried out using NVivo 12. Results This study found that being an international migrant was associated with limited access to both condoms and HIV testing services. Access to condoms was found to vary between countries. Age, educational level, comprehensive knowledge about SRH, comprehensive knowledge about HIV, partner’s age, partner’s educational level and not experiencing IPV in the last 12 months were found to be associated with non-access to condoms. Significant differences in accessing HIV testing services were found by migration status. Other important factors for non-access to HIV testing services were country, educational level, marital status, comprehensive knowledge about SRH and comprehensive knowledge about HIV. The results showed no evidence of an association between migration status and non-utilisation of modern contraceptive methods. Study country was found to be a significant factor with differences between countries in utilisation of modern contraceptive methods. Married and formerly married women had higher odds of not utilising modern contraceptive methods compared to never married women (aOR=1.51, 95% CI 1.08-2.14). In addition, employment status, comprehensive knowledge about HIV and comprehensive knowledge about SRH were found to be associated with utilisation of modern contraceptive methods. Similarly, partner’s educational level and partner’s employment status were found to be associated with utilisation of modern contraceptive methods. There was no significant association between migration status and utilisation of SRH services. Access to healthcare facility and country were important factors in utilisation of SRH referral services. Married women (aOR=1.61, 95% CI 1.09-2.36) and formerly married (aOR=2.14, 95% CI 1.29-3.55) women had higher odds of utilising SRH referral services compared to never married women. For utilisation of intimate partner violence (IPV) services, internal (aOR=0.25; 95% CI 0.06-0.95) and international migrant women (aOR=0.25; 95% CI 0.05-1.21) had lower odds of utilising IPV services. Other factors significantly associated with utilisation of IPV services were age, religion and attitude towards wife beating. The qualitative findings showed that both internal and international migrant women experienced language/communication challenges with international migrant women from Mozambique being the most affected. Migrant women experienced long waiting hours to obtain the required SRH services, negative healthcare worker attitude and discrimination based on migration status, age and HIV status. International migrant women were denied access to SRH and HIV services because they lacked the required documents. International migrant women and to a lesser extent internal migrant women faced negative healthcare worker attitude and discrimination based on migration status. The SRH and HIV services in Ekurhuleni were reported to be affordable, however, geographical inaccessibility resulted in the services being unaffordable because of transportation costs. The provision of SRH and HIV services by male healthcare workers was considered unacceptable by migrant women owing to religious and cultural beliefs. Healthcare workers highlighted experiencing language challenges, cultural and religious challenges, lack of referral or transfer letters and lack of language interpreters as the main barriers in provision of SRH services to migrant women. Conclusion Migration status is an important factor in determining women’s access to condom, HIV testing services and utilisation of IPV services. Internal and international migrant women face challenges in accessing and utilising SRH and HIV services. This is attributed to language barriers, negative healthcare worker attitude, cultural and religious barriers, lack of formal referral services, and discrimination based on migration status, age and HIV status. Migrant women experience language/communication barriers with international migrant women from Malawi and Mozambique being the most affected. To ensure access to and utilisation of SRH services, there is a need for SRH awareness campaigns that target all women regardless of migration status. The findings highlight the need for strategies that tackle religious and cultural beliefs, age specific interventions, and country variations, encourage male involvement, women empowerment and autonomy in accessing and utilising SRH services. This study highlights the need for migrant friendly services including language interpretation and non-judgmental migrant youth friendly services in order to improve the experiences of both migrant women and healthcare workers in accessing and providing SRH services. There is a need for strengthening the referral system within South African health facilities and across the Southern Africa region and promotion of collaboration with non-governmental organisations to minimise unavailability of services and waiting time.enThesis