Research papers (HEARD)

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Giving condoms to school children: educators’ views on making condoms available in South African school.
(African Journal of AIDS Research., 2022) Junck, Leah; George, Gavin
One of the policy goals of the South African Department of Basic Education’s National Policy on HIV, STIs and TB of 2017 is to reduce the incidence of HIV and pregnancy among learners. This is expected to be achieved by improving access to prevention services, including the provision of condoms in schools. This study uses street level bureaucracy theory to explain how educators can play a more productive role in ensuring that policy goals are achieved. Educators provide their views on their role as condom promotion agents, their perception of demand and utilisation among learners, as well as their insights on suitable distribution mechanisms in the school setting. Trepidation exists among educators about their roles in the promotion and education of condoms. Educator statements suggest that they see the value in their policy-ascribed role to deliver sexual health messages and are also open to performing a role in the distribution of condoms at schools. However, our findings reveal that their role as policy communicators or “street-level bureaucrats” is complicated by inadequate policy guidance. We therefore conclude that to achieve optimal outcomes in terms of safer sexual practices among learners, condom messaging and distribution mechanisms in school settings require evidence-informed implementation strategies.
Hegemonic and shamed masculinities: implications of traumatic historical impacts on black men in a post democratic South Africa.
Govender, Kaymarlin.; Cartwright, Duncan James.
The landscape of post-Apartheid South Africa is characterised by high levels of male perpetrated violence against women, children and other men with blame often attributed to victims rather than perpetrators (Hayes & Abbot, 2016). The aberrant behaviours and attitudes of men (also referred to as toxic masculinity) has been central to the notion of a so-called contemporary ‘crisis in masculinity’ with violence and risk taking behaviours (alcohol, substance abuse, sexual risk taking) embedded in male culture. While previous explanations of the ‘modern day crisis’ among men can be largely attributed to South Africa’s history of violent and traumatic struggles of domination over place, ideology and bodies, there is a paucity of work theorising this crisis from a socio-historical and psychodynamic trauma paradigm. In this vein, this paper delves into key periods of our history (referred to as ‘chosen traumas’) that have had persistent disruptive influences on particularly, black masculinity, which have collectively contributed to the modern day crisis. Our argument relies on the idea that unresolved historical traumas have a transgenerational ‘haunting’ effect on contemporary identities (Gordon, 1997; Layton, 2019). Focusing on black men who were subjected to a violent and repressive past, we have argued that ghosts of the pre-Apartheid to post-Apartheid modern day South Africa continue to have cumulative impacts on the black male psyche. It is suggested that these past traumas, together with contemporary representations of black masculinity, have led to a deep sense of unresolved shame, the dynamics of which we have attempted to illuminate using psychodynamic and masculinity theory. The paper concludes with some recommendations on dealing with unresolved traumas and violence.
Community-based maternal and newborn interventions in Africa: systematic review.
(WILEY., 2021) Nishimwe, Clemence.; Mchunu, Gugu G.; Mukamusoni, Dariya.
Aim and objectives: This review analysed the implementation and integration into healthcare systems of maternal and newborn healthcare interventions in Africa that include community health workers to reduce maternal and newborn deaths. Background: Most neonatal deaths (99%) occur in low-and middle-income countries, with approximately half happening at home. In resource-constrained settings, community-based maternal and newborn care is regarded as a sound programme for improving newborn survival. Health workers can play an important role in supporting families to adopt sound health practices, encourage delivery in healthcare facilities and ensure timeous referral. Maternal and newborn mortality is a major public health problem, particularly in sub-Saharan Africa, where the Millennium Development Goals 4, 5 and 6 were not achieved at the end of 2015. Methods: The review includes quantitative, qualitative and mixed-method studies, with a data-based convergent synthesis design being used, and the results grouped into categories and trends. The review took into account the participants, interventions, context and outcome frameworks (PICO), and followed the adapted PRISMA format for reporting systematic reviews of the qualitative and quantitative evidence guide checklist. Results: The results from the 17 included studies focused on three themes: antenatal, delivery and postnatal care interventions as a continuum. The main components of the interventions were inadequate, highlighting the need for improved planning before each stage of implementation. A conceptual framework of planning and implementation was elaborated to improve maternal and newborn health. Conclusion: The systematic review highlight the importance of thoroughly planning before any programme implementation, and ensuring that measures are in place to enable continuity of services. Relevant to the clinical practice: Conceptual framework of planning and implementation of maternal and newborn healthcare interventions by maternal community health workers.
Potential of pumpkin to combat vitamin A deficiency during complementary feeding in low and middle income countries: variety, provitamin A carotenoid content and retention, and dietary reference intakes.
(Taylor & Francis., 2021) Buzigi, Edward.; Pillay, Kirthee.; Siwela, Muthulisi.
The risk of child vitamin A deficiency (VAD) in low and middle income countries (LMICs) begins during the age range of complementary feeding (6–24months), when children are fed complementary foods (CFs) deficient in vitamin A. However, pumpkin, a source of provitamin A carotenoids (PVACs) is widely cultivated in LMICs, but underutilized as a complementary food. Moreover, when consumed by humans, PVACs are bioconverted to retinol, the active form of vitamin A used by the body. This study evaluated the potential of pumpkin toward combating VAD by reviewing varieties of pumpkin cultivated in LMICs and their provitamin A carotenoid (PVAC) content; retention of PVACs in pumpkin during processing it as a CF; and the extent to which a CF prepared from pumpkin may meet the dietary reference intakes (DRIs) for vitamin A for children aged 6–24months old. Pumpkin may combat VAD because the varieties cultivated have high b-carotene content, it is a provitamin A biofortifiable food crop, and 100% retention of PVACs was observed when processed using home cooking methods. Feeding less than 50 g of cooked pumpkin per day meets 100% of the recommended dietary allowance (RDA) and adequate intake (AI) of vitamin A for children 6 to 24months old. Consumption of pumpkin may be used to complement vitamin A supplementation, fortification, and diversification of CFs with animal source foods. For better yield of pumpkin in LMICs, nutrition sensitive agricultural programmes such as biofortification and agronomic management of pumpkin need to be promoted and supported.
Investigating the interrelations between systems of support in 13 to 18 year old adolescents: a network analysis of resilience promoting system in a high and middle-income country.
(WILEY., 2021) Höltge, Jan.; Theron, Linda.; Van Rensburg, Angelique.; Cowden, Richard Gregory.; Govender, Kaymarlin.; Ungar, Michael.
Adolescents’ ability to function well under adversity relies on a network of interrelated support systems. This study investigated how consecutive age groups differ in the interactions between their support systems. A secondary data analysis of cross-sectional studies that assessed individual, caregiver, and contextual resources using the Child and Youth Resilience Measure (Ungar & Liebenberg, 2005) in 13- to 18-year-olds in Canada (N = 2,311) and South Africa (N = 3,039) was conducted applying network analysis. Individual and contextual systems generally showed the highest interconnectivity. While the interconnectivity between the individual and caregiver system declined in the Canadian sample, a u-shaped pattern was found for South Africa. The findings give first insights into cross-cultural and context-dependent patterns of interconnectivity between fundamental resource systems during adolescence.
The impact on HIV testing over 6 months when free oral HIV self-test kits were available to truck drivers in Kenya: a randomized controlled trial.
(Frontiers Media S.A., 2021) Kelvin, Elizabeth A.; George, Gavin.; Romo, Matthew L.; Mantell, Joanne E.; Mwai, Eva.; Nyaga, Eston N.; Odhiambo, Jacob O.; Govender, Kaymarlin.
Background: Studies suggest that offering HIV self-testing (HIVST) increases short-term HIV testing rates, but few have looked at long-term outcomes. Methods: We conducted a randomized controlled trial (RIDIE 55847d64a454f) on the impact of offering free oral HIVST to 305 truck drivers recruited from two clinics in Kenya. We previously reported that those offered HIVST were more likely to accept testing. Here we report on the 6-month follow-up during which intervention participants could pick-up HIVST kits from eight clinics. Results: There was no difference in HIV testing during 6-month follow-up between participants in the intervention and the standard of care (SOC) arms (OR = 1.0, p = 0.877). The most common reasons given for not testing were lack of time (69.6%), low risk (27.2%), fear of knowing HIV status (20.8%), and had tested recently (8.0%). The null association was not modified by having tested at baseline (interaction p = 0.613), baseline risk behaviors (number of partners in past 6 months, interaction p = 0.881, had transactional sex in past 6 months, interaction p = 0.599), nor having spent at least half of the past 30 nights away from home for work (interaction p = 0.304). Most participants indicated a preference for the characteristics associated with the SOC [preference for blood-based tests (69.4%), provider-administered testing (74.6%) testing in a clinic (70.1%)]. However, those in the intervention arm were more likely to prefer an oral swab test than those in the SOC (36.6 vs. 24.6%, p = 0.029). Conclusions: Offering HIVST kits to truck drivers through a clinic network had little impact on testing rates over the 6-month follow-up when participants had to return to the clinic to access HIVST. Clinic-based distribution of HIVST kits may not address some major barriers to testing, such as lack of time to go to a clinic, fear of knowing one’s status and low risk perception. Preferred HIV testing attributes were consistent with the SOC for most participants, but oral swab preference was higher among those in the intervention arm, who had seen the oral HIVST and had the opportunity to try it. This suggests that preferences may change with exposure to different testing modalities.
An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: a 12-month follow-up study.
(WILEY., 2021) Angwenyi, Vibian.; Bunders-Aelen, Joske.; Criel, Bart.; Lazarus, Jeffrey V.; Aantjes, Carolien Jeanette.
This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.
Why doesn't the decriminalization of same sex sexuality and sex work ensure rights? : the legality and social acceptance of transgressive sexualities in urban Mozambique.
(Springer., 2021) Aantjes, Carolien Jeanette.; Munguambe, Khátia.; Muchanga, Vasco.; Capurchande, Rehana.; Poku, Nana K.
Background: The dependence on the law to direct people’s behaviour is known for its imperfections, yet it has become a mainstream response to social problems in modern day society. It is also the pathway through which internationally-recognised rights obligations, including sexual rights, are anticipated to diffuse across distinctly different societies. We studied the introduction of new legal standards in Mozambique, with an interest in their ability to promote the rights of lesbian, gay, bisexual, transgender, intersex (LGBTI) people and sex workers. Methods: Between 2019 and 2020, we conducted sixteen key informant interviews with jurists, policymakers, and civil society advocates at national level and seventy-eight interviews with opinion leaders from local communities in three urban sites situated across Northern, Central, and Southern Mozambique. Results: The new legal standards, in which same-sex sexuality and sex work are no longer criminalised, found little resonance with intersecting religious, sexual, gender, and socio-cultural norms. Whilst there was a consensus not to discriminate, sensitisation and rehabilitation of LGBTI people and sex workers were considered imperative. This stance, coupled with a continued presence of ambiguous language in and incongruences between legislative pieces, attenuates the country’s commitment to internationally recognised rights obligations. Conclusions: In a context of weak civilian awareness and support, the legal reforms are not likely to make a profound positive impact on the lives of LGBTI people and sex workers. Policy action should extend beyond health and law enforcement institutions and draw in community leaders to mediate the social processes that undercut the universality of rights.
Capacity development in pursuit of social change: an examination of processes and outcomes.
(Routledge., 2021) Aantjes, Carolien Jeanette.; Burrows, Dave.; Armstrong, Russell.
Understanding “what works” for capacity development support in an international development setting remains an important area for operational research. This mixed-methods study explored this topic within a global programme that supports civil society organisations in fifteen countries to secure the health and human rights of marginalised and underserved populations. Taking a complex adaptive systems approach, and seeking to understand the phenomena from the “receiver” perspective, the study found that the programme fostered the development of four interconnected domains of capacity through a reflexive, user-led approach. These capacity gains could be linked, although not causally, to important programmatic achievements for the programme’s focus populations.
Paediatric tuberculosis preventive treatment preferences among HIV-positive children, caregivers and healthcare providers in Eswatini: a discrete choice experiment.
(BMJ Open., 2021) Hirsch-Moverman, Yael.; Strauss, Michael.; George, Gavin.; Mutiti, Anthony.; Mafukidze, Arnold.; Shongwe, Siphesihle.; Dube, Gloria Sisi.; El Sadr, Wafaa M.; Mantell, Joanne E.; Howard, Andrea A.
Objective: Isoniazid preventive therapy initiation and completion rates are suboptimal among children. Shorter tuberculosis (TB) preventive treatment (TPT) regimens have demonstrated safety and efficacy in children and may improve adherence but are not widely used in high TB burden countries. Understanding preferences regarding TPT regimens’ characteristics and service delivery models is key to designing services to improve TPT initiation and completion rates. We examined paediatric TPT preferences in Eswatini, a high TB burden country. Design: We conducted a sequential mixed-methods study utilising qualitative methods to inform the design of a discrete choice experiment (DCE) among HIV-positive children, caregivers and healthcare providers (HCP). Drug regimen and service delivery characteristics included pill size and formulation, dosing frequency, medication taste, treatment duration and visit frequency, visit cost, clinic wait time, and clinic operating hours. An unlabelled, binary choice design was used; data were analysed using fixed and mixed effects logistic regression models, with stratified models for children, caregivers and HCP. Setting: The study was conducted in 20 healthcare facilities providing TB/HIV care in Manzini, Eswatini, from November 2018 to December 2019. Participants: Ninety-one stakeholders completed in-depth interviews to inform the DCE design; 150 children 10–14 years, 150 caregivers and 150 HCP completed the DCE. Results: Despite some heterogeneity, the results were fairly consistent among participants, with palatability of medications viewed as the most important TPT attribute; fewer and smaller pills were also preferred. Additionally, shorter waiting times and cost of visit were found to be significant drivers of choices. Conclusion: Palatable medication, smaller/fewer pills, low visit costs and shorter clinic wait times are important factors when designing TPT services for children and should be considered as new paediatric TPT regimens in Eswatini are rolled out. More research is needed to determine the extent to which preferences drive TPT initiation, adherence and completion rates.
Estimating the financial incentive for Caribbean teachers to migrate: an analysis of salary differentials using Purchasing Power Parity (PPP).
(University of the West Indies., 2021) George, Gavin.; Rhodes, Bruce.; Laptiste, Christine.
The teaching stock within the Caribbean region has been eroded by migration to developed countries. Higher potential earnings are one of the motivating factors to move abroad, but little is known about the extent of the income disparity between countries in the Caribbean and popular destination countries. Teacher salary comparisons are undertaken between selected countries in the Caribbean; Suriname, Trinidad and Tobago, St. Lucia, and Jamaica and popular destination countries, namely; United Kingdom, United States, and Canada using a purchasing power parity (PPP) exchange rate. Results show that newly qualified teachers can earn substantially more abroad, with Canada paying over twice the PPP adjusted salary compared to that offered in Jamaica (133.1%) and Suriname (110.6%). The United States offers the highest earning increases for mid- and late career teachers at over three times that offered in Jamaica (214.5%) and Suriname (223.4%). Canada is a close second across all Caribbean countries, whilst the United Kingdom offers the smallest salary differentials at 153.6% for Jamaica and 64.8% for St. Lucia. The study further reveals that there are salary disparities within the Caribbean, which may be a motivating factor for intra-regional migration.
Death and the sociocultural dimensions of forced relocations: experiences from the Tugwi-Mukosi displacement in Masvingo Province, Zimbabwe.
(Routledge., 2021) Basure, Hardlife Stephen.; Nhodo, Lloyd.; Dube, Charles.; Kanyemba, Roselyn.
This article is an ethnographic inquiry into the cultural dimensions of forced relocations. It is based on the experiences of four resident anthropologists on the forced displacements at Tugwi-Mukosi in Masvingo province, Zimbabwe. Using the concept of death, we question the idea of belonging and what is regarded as an “honourable” way of exiting this world. These are interwoven in the cultural fabric of most Zimbabwean communities and any phenomenon that severs this tie to home is a cause of discomfort and pain amongst local people. Forced displacements have altered issues of honour associated with death rituals. We use death rituals as a window to understand the sociocultural effects of displacement. Novel ways of dealing with death are witnessed as people struggle with lack of a permanent “home.” The sacredness of cultural dimensions of death has been reconfigured in ways that have left the displaced struggling to find closure in dealing with the dead. Death rituals give us an opportunity to understand the multifaceted effects of displacement. Through death we experience the pain of displacement, understand the chords that bind the displaced communities together and witness the enduring social bonds that structure life beyond the disruptions of displacement.
Review of the inclusion of SRHR interventions in essential packages of health services in low and lower-middle income countries.
(Taylor & Francis., 2021) Hepburn, Jasmine Sprague.; Mohamed, Idil Shekh.; Ekman, Björn.; Sundewall, Jesper.
Sexual and reproductive health and rights (SRHR) and universal health coverage (UHC) are fundamental to health as a human right. One way that countries operationalise UHC is through the development of an essential package of health services (EPHS), which describes a list of clinical and public health services that a government aspires to provide for their population. This study reviews the contents of 46 countries’ EPHS against the standard of the Guttmacher-Lancet Report’s (GLR) nine essential SRHR interventions. The analysis is conducted in two steps; EPHS are first categorised according to the level of specificity of their contents using a case classification scheme, then the most detailed EPHS are mapped onto the GLR’s nine essential SRHR interventions. The results highlight the variations of EPHS and provide information on the inclusion of the GLR nine essential SRHR interventions in low- and lower-middle income countries’ EPHS. This study also proposes a case classification scheme as an analytical tool to conceptualise how EPHS fall along a spectrum of specificity and defines a set of keywords for evaluating the contents of policies against the standard of the GLR. These analytical tools and findings can be relevant for policymakers, researchers, and organisations involved in SRHR advocacy to better understand the variations in detail among countries’ EPHS and compare governments’ commitment to SRHR as a human right.
Stakeholders perceptions regarding implementing maternal and newborn health care programs in Rwanda.
(Springer Nature., 2021) Nishimwe, Clemence.; Mchunu, Gugu G.
Background: While maternal and newborn deaths has been decreasing since 2008 in Rwanda, there is room for improvement to meet its sustainable development goals. The maternal and newborn health care program needs to be monitored to ensure its effective implementation. This study therefore aimed to explore stakeholder’s perceptions of the Rwandan maternal and newborn health care program to identify areas for improvement. Methods: The convergent, parallel, mixed method study used quantitative and qualitative data in a single phase. The quantitative data was obtained from 79 health care workers, ranging from maternal community health care workers to program supervisors. The 10 areas of the Project Implementation Profile (PIP) instrument checklist with a five-point Likert scale were used to indicate their perceptions (strongly disagree to strongly agree). The qualitative interviews of five nurse managers used a manifest inductive content analysis, directed approach that entailed using existing theory and prior research to develop the initial coding scheme before starting data analyse. Results: There was disagreement about the level of top management support, human resources was regarded as an area of concern, with 18.7% (n = 14/79) indicating that they did not agree that this was adequately provided for; urgent solutions for unexpected problems was regarded as an areas of concern by 46.8% (n = 36/79). Top management support weakness were inadequate support training, materials, money for home visits, supervision and leaderships, and training of newly recruited maternity health care workers. For human resources, there were insufficient trained staff to take care of mothers and newborns due to the shortages of health providers. The management of unexpected problems was also an area of concerns and related to getting patients to health facilities during pregnancy emergencies and the lack of qualified birth attendants at health facilities. Conclusion: The study identified three areas for improvement: top management support, human resources and urgent solutions for unexpected problems, as they may be affecting the provision of maternal and newborn health care program services. Using the PIP enable managers to improve the country’s maternal and newborn health care program, and to provide ongoing monitoring and evaluation of with respect to the desired outcomes of reducing maternal and neonatal mortality.
Body image and antiretroviral therapy adherence among people living with HIV: a protocol for a systematic review and meta-analysis.
(BMJ Open., 2021) Nyamaruze, Patrick.; Cowden, Richard Gregory.; Padgett, R Noah.; Govender, Kaymarlin.
Introduction Adherence to antiretroviral therapy (ART) remains a key challenge to achieving the fast-track goal of ending the HIV epidemic by 2030. To provide a more comprehensive indication of whether interventions designed to promote ART adherence might benefit from targeting body image perceptions, we aim to conduct a systematic review to synthesise existing evidence on the association between body image and ART adherence. Methods and analysis A systematic review of peer-reviewed observational studies and randomised controlled trials that have investigated the association between body image and adherence to ART will be performed. JSTOR, PsycARTICLES, PsycINFO, PubMed, ScienceDirect and Web of Science databases will be searched from 1 January 2000 to 31 March 2021. Eligible records will consider body image as either an independent variable or a mediator, whereas ART adherence will be assessed as an outcome variable. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and study quality will be assessed using relevant tools developed by the National Institute of Health. If sufficient data are available, a meta-analysis will be conducted. Effect size estimates will be aggregated using a random effects meta-analysis approach. Publication bias and its impact will be evaluated through the use of a funnel plot and the trim-and-fill method. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to report on the overall quality of evidence.
Joint modelling of malaria and anaemia in children less than five years of age in Malawi.
(Elsevier., 2021) Gaston, Rugiranka Tony.; Ramroop, Shaun.; Habyarimana, Faustin.
Background: Malaria and anaemia jointly remain a public health problem in developing countries of which Malawi is one. Although there is an improvement along with intervention strategies in fighting against malaria and anaemia in Malawi, the two diseases remain significant problems, especially in children 6–59 months of age. The main objective of this study was to examine the association between malaria and anaemia. Moreover, the study investigated whether socio-economic, geographic, and demographic factors had a significant impact on malaria and anaemia. Data and methodology: The present study used a secondary cross-sectional data set from the 2017 Malawi Malaria Indicator Survey (MMIS) with a total number of 2 724 children 6–9 months of age. The study utilized a multivariate joint model within the ambit of the generalized linear mixed model (GLMM) to analyse the data. The two response variables for this study were: the child has either malaria or anaemia. Results: The prevalence of malaria was 37.2% of the total number of children who were tested using an RDT, while 56.9% were anaemic. The results from the multivariate joint model under GLMM indicated a positive association between anaemia and malaria. Furthermore, the same results showed that mother's education level, child's age, the altitude of the place of residence, place of residence, toilet facility, access to electricity and children who slept under a mosquito bed net the night before the survey had a significant effect on malaria and anaemia. Conclusion: The study indicated that there is a strong association between anaemia and malaria. This is interpreted to indicate that controlling for malaria can result in a reduction of anaemia. The socio-economic, geographical and demographic variables have a significant effect on improving malaria and anaemia. Thus, improving health care, toilet facilities, access to electricity, especially in rural areas, educating the mothers of children and increasing mosquito bed nets would contribute in the reduction of malaria and anaemia in Malawi.
Probing the context of vulnerability: Zimbabwean migrant women’s experiences of accessing public health care in South Africa.
(African Human Mobility Review., 2021) Mutambara, Victoria M.; Naidu, Maheshvari.
South Africa has a professed inclusive health policy that articulates that everyone is entitled to have access to health-care services, regardless of nationality and citizenship. However, several challenges exist for migrant women in South Africa, in accessing this health care. This paper, based on the experiences of Zimbabwean migrant women residing in Durban, focuses on their experiences of seeking and accessing health-care services in South Africa. Using a qualitative study design, semi-structured interviews were conducted with 22 purposively sampled female participants aged 25–49 years. This paper employs a structural-violence analysis to probe the underlying factors that make it challenging for Zimbabwean migrant women to access public health-care services in South Africa. The findings of this paper highlight that the lack of valid immigration documentation, often makes it challenging for participants to access services from public hospitals and clinics. The findings also reveal that the state of the South African public health-care system predisposes migrant women to health risks.
Assessing the impacts of COVID-19 on women refugees in South Africa.
(Oxford University Press., 2021) Mutambara, Victoria M.; Crankshaw, Tamaryn L.; Freedman, Jane.
The global COVID-19 pandemic and subsequent lockdowns and restrictions have had uneven impacts on populations and have deepened many pre-existing inequalities along lines of race, ethnicity, class, gender. Refugees have been shown to be particularly negatively impacted in many countries, with existing structures of violence and insecurity worsened by the immediate consequences of the pandemic through policy responses which largely ignore their needs whether by excluding them from targeted COVID-19 mitigation measures, or by imposing restrictions which directly impact on their well-being. Our research with refugee women in Durban, South Africa, illustrates the ways in whichCOVID-19 has exacerbated their insecurities and intensified structural violence which renders them vulnerable. More importantly, it seems that the impacts of COVID-19 are not just short term but will deepen the violence and insecurities experienced by these women in the longer term if these are not addressed by government and relevant NGOs and civil society organizations.
Analysing the economies of transactional sex amongst young people: case study of Madagascar.
(Elsevier., 2021) Freedman, Jane.; Rakotoarindrasata, Mina.; de Dieu Randrianasolorivo, Jean.
This article aims to explore the social and economic determinants of transactional sexual (TS) relationships in Madagascar, to explain the normalisation of this type of relationship amongst young women, and the increasing involvement of young men. We aim to contribute to existing research on TS by showing the complexities of the meanings and pathways into TS which are not limited to economic necessity, and the blurred boundaries between TS and other forms of sexual exchange. We will argue that for young women in Madagascar engaging in TS is a choice which is constrained by structures of poverty and wider gender inequality, structures which lead to the transformation of traditional gender norms within a wider globalised economy of sexual exchange. These highly unequal structures can further be argued to perpetuate and reproduce various forms of violence both through the modification of traditions and customs, and within newer forms of TS relationships such as those with foreign men. Whilst it might seem an impossible task to address all these determinants of TS relationships in Madagascar in order to reduce the constraints and violence exercised against these young women, their situation could be improved through better programmes and services addressing their needs, and particularly their sexual and reproductive health needs.
Age Matters: determinants of sexual and reproductive health vulnerabilities amongst young women who sell sex (16–24 years) in Zimbabwe.
(Elsevier., 2021) Crankshaw, Tamaryn L.; Chareka, Samantha.; Zambezi, Pemberai.; Poku, Nana K.
Introduction: Female sex workers bear a disproportionate burden of HIV and other poor sexual and reproductive health (SRH) outcomes which has led to the tailoring of SRH interventions to mitigate risk. Understanding of the SRH vulnerabilities of young women who sell sex (YWSS) (16–24 years) in Southern Africa is under-represented in research which may result in a mismatch in current SRH interventions and service design. Objective: This paper is based on a sub-analysis of a qualitative study investigating the SRH of young women who sell sex (16–24 years) in Zimbabwe. We explored the differences in dynamics of SRH vulnerability amongst YWSS within the 16–24 year age band. Methods: In-depth interviews (IDIs) were conducted amongst key informants (n = 4), health care providers (n = 5), and peer educators (n = 16). Amongst YWSS, we conducted IDIs (n = 42) and focus group discussions (n = 30). Transcripts were inductively coded for emergent themes and categories. Results: Age and life stage determinants led to key differences in SRH vulnerabilities between younger (16–19 years) and older YWSS (20–24 years). These determinants emerged in the following ways: 1) distancing of younger participants from a “sex worker” identity leading to difficulties in identification and limiting intervention reach, 2) inexperience in dealing with clients and immature cognitive development leading to greater exposure to risk, and 3) the subordinate social position and exploitation of young participants within sex worker hierarchies or networks and lack of protective networks. Conclusions: We highlight the presence of a diverse group of vulnerable young women who may be missed by sex worker programme responses. In future intervention planning, there is need to consider the age-related needs and vulnerabilities within a spectrum of young women involved in a wide range of transactional relationships to ensure that services reach those most vulnerable to poor SRH outcomes.

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