Redressing Gendered Health Inequalities of Displaced Women and Girls in contexts of Protracted Crisis in Central and South America (ReGHID)

Lead Research Organisation: University of Southampton
Department Name: Sch of Economic, Social & Political Sci

Abstract

Women and young girls who are driven by necessity to leave their countries in Central and South America (often on basis of gendered threats such as sexual violence) face a range of gender-specific threats to their health and well-being both in the process of migrating and in the places of settlement that they reach. Sexual and reproductive health is a key component of social development and well-being that is particularly at risk in contexts of displacement (risks of rape and sexual assault, of sexual disease, of lack of contraception or sanitary materials are all features of processes of forced displacement in this region and elsewhere) and the ability of displaced women and girls to access and exercise their sexual and reproductive health rights faces a number of obstacles. These can range in the immediate local context from lack of awareness of rights or of the practical knowledge and skills to negotiate health systems on the part of displaced women and girls to the lack of capacity of local health services to address the needs of displaced females, where these immediate problems point to wider issues of national and regional health governance, of the need for effective planning for flexible responsiveness to crises of displacement that may become protracted and the fair sharing of responsibility for securing rights protection. This matters not only because securing these rights is integral to recognising the dignity of women and girls, but also because it is critical to enabling displaced women and girls to act as agents of development, as productive social and economic agents whose activities support the achievement of Sustainable Development Goals.

ReGHID will:
- identify the sexual and reproductive health needs of women and adolescent girls displaced from Central America to Mexico and from Venezuela to Brazil and Colombia;
- analyse the challenges that displaced women and girls face in relation to SRH;
- assess the impact of displacement on local health systems in the area of SRH, noting the obligations of receiving and transit states to ensure that the human right to health for all is respected and protected;
produce original primary data about gendered patterns of inequalities affecting access to and delivery of care in women and girls' SRH during displacement.

It does so in order to propose human rights-based and deliverable responses addressing (a) the immediate and longer-term SRH needs of women and adolescent girls in displacement, including guidance, skills and information to equip them to articulate their SRHR; and (b) a responsive Comprehensive Healthcare Model as a policy solution to protect the SRHR of migrant women and girls in contexts of protracted displacement.
To be able to do this work, the project has been co-designed, and will be cooperatively carried out, through a partnership between academics and major UN and NGO agencies from the fields of migration, displacement, aid and development. The project will be delivered by an interdisciplinary and international consortium that unites leading academics from health economics, political science, demography and social statistics, international development, human rights, gender studies, anthropology, migration and public health. Participants are drawn from leading research institutions in Central and South America region (Honduras, El Salvador, Brazil, Colombia and Mexico), the Universities of Southampton and York. It benefits from the participation of key regional intergovernmental and non-governmental organisations including the Council of Ministries of Health for Central America (COMISCA), the regional office of the International Organisation for Migrations (IOM), Medicos Sin Frontera (MSF, Mexico), United Nations Population Fund (UNFPA), and FLACSO/Costa Rica. The consortium represents a unique balance of relevant research and policy experience

Planned Impact

Impact has been embedded in the design of this proposal with NGOs, IOM and regional organisations. ReGHID will have an impact on:
i) Non-governmental and inter-governmental organisations (MSF, COMISCA, IOM) through co-design and co-delivery of impact outputs and activities into their routines and programming by co-designing an AGAPE guidance manual to ensure better SRH outputs for displaced women and girls, support the identification of health threats, health needs and barriers in the way of health rights (whether formal or informal). Further outputs such as short documentary videos and printed material will support collaborative awareness campaigns for better protection, monitoring and management of community aid.
ii) National policy makers in Central and South America with new data profiling SRH needs of women and girls in displacement from Central America and Venezuela, how those needs are met in places of transit and abode and how met/unmet SRH affect women and adolescent SRH rights, that will inform planning to improve capacity and respond effectively to health needs affected by displacement improving at the same time the prospects of displaced women and girls to be integrated in society, to develop an independent and healthily life. In addition, the health system policy modelling (MIAS -NS) closely aligns with strategic developmental goals set out nationally, regionally and in the SDG commitments on poverty reduction, health, gender, migration and development partnership.
iii) Displaced women and adolescent girls, communities, local healthcare workers, health and gender activists and civil society groups through age-appropriate information packs for girls aged 10 to 14 years and 15-24, working with ongoing IOM and MSF support and advocacy strategies. By producing immersive short video documentaries and photovoice ReGHID will also give displaced people a voice and create material for further public awareness and training sessions with community and health authorities.
iv) Scholars and researchers across the fields of social science (politics, development, international relations, human geography, demography), health economics and public health; with particular focus on ECR who will contribute to research activities and work closely with policy makers, NGOs and intergovernmental organisations such as IOM and COMISCA.
v) GCRF South-South Migration, Inequality and Development Hub with new empirical and conceptual material that offers a rights-based approach to health of forced female migrants and displacement as a determinant of sustainable wellbeing of societies and development for all. ReGHID will improve academic and policy relevant knowledge generating and disseminating new data on the SRH status of the most vulnerable groups within the forced migration populations, women and adolescent girls in South-South migration corridors leaving from and arriving at the most unequal countries in Central America and South America. ReGHID will engage with the Hub sharing of findings and best practices.
Outreach and impact will be achieved through a set of activities in partnerships with NGOs, IOM, and displaced women and adolescent girls throughout the work packages, including participatory research, face-to-face meetings, workshops, seminars and public engagement activities thorough awareness campaigns and advocacy using printed and visual material. We will also set up a project website to disseminate bilingual project information briefs, reports, papers and E-newsletters, and link with partners' media outlets and mailing lists. We will also develop opportunities for transfer knowledge for stakeholders to provide feedback and context, and for academics, practitioners and advocacy groups. We will provide a legacy of cross-disciplinary and cross-organisation capacity building, which will provide a self-sustaining network of north-south and south-south researchers and a framework enabling international partnership.

Publications

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Description Despite Covid and with the necessary adjustments in terms of activities, progress in the first year of the project has been successful in terms of meeting the objectives for the reported period. Some new knowledge has been generated and translated into short investigative pieces, blogs and webinars- all of which consolidated networks and raised the profile and outreach of the project. Other outputs have been a comprehensive and systematic literature review, titled 'Missing Voices and the Paradox of Power and Choice: In the Sexual and Reproductive Health Challenges of South-South Migrant Girls and Women in Central America and Mexico', and a Working Paper titled 'What a human right to health approach means in situations of displacement in relation to Sexual and Reproductive Health and who bears what duties for its delivery?'. These documents established the theoretical-philosophical bases of the project and are being produced for peer reviewed publication. The findings of these two draft papers were also presented in international webinars and in the launching of the project that included the Advisory Board.

We also published another paper that scopes the literature, and after a series of interviews, focus groups and survey implemented in Brazil and In Honduras, data on needs and barriers to sexual and reproductive health of migrants have been collected.

During the second year, based on research and engagement activities with stakeholders and members of the Advisory Board, we developed a new research resource, a quantitative survey, to assess SRHR needs of women and girls in displacement, availability and appropriateness of health systems to support their specific SRHR in places of transit and settlement, and to assess determinants of health inequalities affecting displaced women of reproductive ages. The survey is a key tool to provide new data on SRH needs of displaced women and adolescent girls and analysis of SRH status alongside analysis of met and unmet SRH health and rights. This will be implemented in the second year of the project in ODA countries, El Salvador, Honduras and in Brazil. Because of Covid, the implementation of the surveys were severely delayed so we are now in the process of cleaning data and analysis. This represent a delay of about 6-9 months.

Both survey instruments caught the attention of the International Organization for Migration showed interest in adopting the instrument in their programatic agenda. As such, they agreed to be part of a training session where researchers from University of Southampton trained the staff of IOM to implement the survey in Central America. A pilot of the imply,entation of the survey took place as a consequence led by IOM staff in Honduras in February 2022.

We also developed an information guide (AGAPE guide) coproduced with migrant women from Venezuela in Colombia, which is going to be piloted as a pair formation tool for migrant women to act as leaders informing about right to health to other migrants.

We conducted online activities hosted by FLACSO El Salvador, reaching key scholars, policy makers, service providers and NGOs from ODA recipients that face challenges that displacement pose to the achievement of SDG goals, principally health and gender-related SDG targets in El Salvador, Honduras, Colombia, Nicaragua, Panama, Ecuador and Brazil Republic that are increasingly becoming countries of abode for forced migration in Central America and Venezuela.

We met as a project face to face in Bogota, March 2-5 2022, to present findings and progress to the members of the Advisory Board, who gave positive feedback and suggestions for enhancing impact.

PRELIMINARY FINDINGS and Emerging themes from the migration corridor Venezuela-South America:
During the Migration journey
• Venezuelan migrants should be considered "necessary-fleers": they leave mostly for socio-econ reasons, poverty, health problems, to help family (remittances), much less for political reasons or persecution
• Method of travel reflects a distinction in terms of demographic characteristics of migrants and is a determinant of SRH risks in displacement and will determine who 'receives' the migrants when they arrived in Brazil. Also determines what sort of information they meet - as provided by whom.
Travelling by trochas, an irregular form of travelling, walking and/or driving by alternative, non urbanised paths. Organised by trocheros/ smugglers (different in the journey as it divided by trenches). They are paid, and may change their minds and demand more payment as they go along - or demand sex from women. Women/girls tend to sell clothes and other items as payment as well. Personal belongings tend to be stolen at some point or left behind due to weight. SGV and no places to shower or change as it is jungle and mountains. Length depends but can take 5-7 days. Increased irregular crossing by trocha since closing border March 2020 (border with Venezuela).These are the poorest migrants who take very risky method of travel. Arrive at different places, depends where trochero takes them and sometimes helped by indigenous communities and church (in the area/outskirts of Pacaraima or may continue journey) upon arrival
Those arriving by bus are safer, they travel via a regular manner, as going through the legal pathways and stopping at the Federal Police station in the border with Pacaraima. Where military police give them information. Length: 1 to 3 days. Less risky, stop by petrol station and women tend to use bathroom/shower facilities.
• The way of travelling also determines where they will reside: there is a tendency of those arriving by trocha ending in abrigos or street (rodoviaria) or going to rented accommodation if they know someone. Those by bus tend to go to abrigos (less), but mostly live in rented accommodation. Information for those that travel by trocha and go straight to rented accommodation is scarce because abrigos tend to be focus of information. Most coming by bus are more established and will tend to know where to look for information about protection and healthcare

- Border policy determines the way of travel and opportunities to get documentation: This speaks very strongly to the securitization of both migration and health. being documented/undocumented matters when in Brazil. All Venezuelan crossing borders after march 2020 will be undocumented hence enter an illegal pathway from origin to place of abode. But doesn't matter for access to healthcare in settlement - not a barrier to access basic health services. Often when they arrive they immediately know there is a 'carton saude' that they need to get. By word of mouth, institutions like UNHCR, Adra, UNFPA, militares (who coordinate Operacion Acolhida - welcoming programme) are normally the focal point of information

• Intersecting vulnerabilities. One consequence of the conditions of migration and the process itself is 'perdida de referencia familiar' loss of reference/ family anchor:
o Women/adolescent may travel alone, leave family behind, leave to support family but poverty, lack of employment, language and other barriers attempt against opportunities to integrate in the job market and become autonomous, and support families or left behind. There is no sustainability and even more (protracted) precarity
o the gendered risks of migration deepen with time - and new ones are created.
o Gender violence: during and after displacement.
o Deepening of 'toxic masculinities' as myth of 'hombre proveedor' etc fall, increased unbalance of gender power that leads to violence -- SGBV and unwanted pregnancies
o Lack of information re rights, health services and systems of protection

Displacement is a determinant of SRH
• Choices that women and adolescents made to respond to, and cope with, risks faced in displacement bring about new risks of SRH that may force to take new decisions and thus new risks. For instance, women exchange sex for food while in displacement. For example, women migrate to Brazil undocumented in the hope they will find better jobs, prospects or SRH services. That choice raises a series of (SRH) risks that lead to new decisions and coping mechanisms. Another example is Warao women leaving decision about their health to (the authority of) men or shaman who define what is urgency and needed for them, reproducing modalities of gatekeeping and choice made for them, that affect their autonomy and may not respond to their health needs. We want to explore further in the interviews how this continuum of choice/risk/autonomy manifests in different ways.
• Protracted displacement is a consequence of poverty, stigma, Violence, lack of settlement / integration and reproduces poverty. There is no one taking responsibility for these women's dignity, and displacement seems the ever-lasting answer. Migration pattern seems to flow from Pacaraima - Boa Vista - Manaus , and for many women Manaus seems to be a 'step up' in comparison to Boa Vista, i.e., a bigger city with more opportunities. Many mention bad experiences in shelters in Boa Vista as well as in the health system in the state of Roraima. For some, Manaus is a waiting place (and therefore a place of transit), as they want to go elsewhere (the majority to Santa Catarina, some to São Paulo) but are waiting for something, normally their documents

• Missing voices/ lack of agency: of women migrants in terms of the identification of their own needs and risks. Many services provided by NGOs assume principles of rights and needs, as well as what is urgent and risk. Also gatekeeping and oppression as women and girls may not be heard in their needs and feelings. They learn to cope, they normalise situations of harm for being women and for being migrants, they received what they are offered in terms of services and information.
• There seems to be a general lack of spaces for these women to express themselves; to talk, to find spaces for sharing experiences or seek / discuss information and support
• Naturalization of violence and pain: many women seem to normalise the pain in their bodies and the violence they suffer in the process of migration and once in settlement , especially institutional violence

Barriers to access to healthcare faced by migrant women and girls
• Language
• Lack of privacy as barrier to the exercise of SRH rights. Bathrooms in shelters a communal, sleeping conditions are open with many mattresses in spaces separated by bed sheets. other seems to be a key SRH issue for women in displacement and when settled in public shelters in Manaus. Shelters also seem to raise concerns regarding intimate hygiene, with a case of urine tract infection. Adolescent girls may feel uncomfortable changing pads during menstruation in communal bathrooms or might be encouraged to use menstrual cups for being 'more hygienic' (interview ONU Mujeres)
• Barriers: Lack of information (which services, what to do and who is responsible - no one cares, institutional violence) and language barriers - this is particularly generalised in interviews

Plus, Poverty, Sense of shame and insecurity (trans women do not leave their rooms in abrigos/shelters because of fear). Some women in Manaus speak of discrimination in the health system, but it seems to be an exception thus far, as most do not refer to discrimination as a barrier to access. But in general, no clear sense of discrimination, but we have to explore it better, do they naturalize the institutional violence they suffer?

Information needs
• Abrigos/shelters function as information hubs, and 'grupo de apoyo'. Gaps in local information may be complemented by abrigos. Also NGOs work with/in abrigos
• Temporality and displacement dynamics: the more time they spend in a place the more information they may receive and thus adapt their health seeking behaviour to that info. Information shapes their sense of right to health (about getting the saude/health card, what they should be aware of in terms of health and health behaviour etc).
• Time also affects the continuum of unmet health needs and rights, as some women spend months - and years - waiting for specialised SRH and health attention

• Women in Manaus in general are very thankful to the system and seem to navigate it well. However, many found information on SRHR only in shelters, from NGOs, friends, or the military, not the health system itself - and the governmental health system does not seem to be a pro active actor in terms of providing information or covering such gap, outsourcing its own responsibility to third parties.
• Bus station in Manaus seem to represent a multiplicity of things for migrants in Manaus: a space they consider a shelter (albeit not called as such by institutions), a place of sociability (many Venezuelan women, even those that don't sleep there, go to the bus station to meet friends and talk to other Venezuelans), a space where they can get free food (even if not living there, all Venezuelans have access to free lunch. Many women, even those that rent their houses, go to the bus station daily to be able to have access to a meal), and a space to gather information (many women get most or all of their info on SRHR in the bus station. Some of those that don't live there see the bus station as a space where they can go to obtain all sorts of information, either from other migrants or from organisations that go/work there).
• information on SRH mainly related to type/use of contraceptives
• lack of info re prenatal care, more info wanted on family planning
• Translators needed for health consultations

Systems of protection/responsibility
• The overall health system's approach seems to excessively focus on sexual health and trauma. System of protection could be categorized as: vertical, emergency and humanitarian response with a short-term approach, not human rights encompassing, in order to mitigate problems not change them. Health approach seems to have an excessive focus on sexual health and behaviours, as well as protection only related to trauma from violence. The sense we get from 'protection' regarding SRHR is protect to avoid more pregnancies, more traumas, STIs, to avoid more impact in the system and in the local community, with a lesser approach to human rights (overly focus on human security?). There doesn't seem to be a comprehensive, sustainable and long-term approach to SRH protection for migrants. Equally, there doesn't seem to be a comprehensive and age disaggregated approach to sexual & reproductive health of migrant women and adolescent girls.
• Organisations such as ACNUR also act as gatekeepers of the shelters they support. Together with UNFPA and IOM, they are identified by women as information providers. They triage in some cases or profile needs and situations that need protection to then orient where to go.
• important role of the UN, which women broadly identify without specifying specific agencies, with some exceptions. The military are also integral regarding SRHR services and information, as well as the Church. In Manaus, specifically, ADRA, an Adventist organisation seems to play a pivotal role. ADRA seems to be too involved with giving information on (and maybe giving out?) contraceptives. We have to better investigate the range of its role, is there anything conservative about it? What and how do they approach family planning in their workshops? Trans women, however, have so far solely mentioned UNFPA.
• Contradictions in protection: Brazil, for instance, recognises Venezuelans as refugees but have left the Global Compact;
• Pass the buck experience within health services in certain cases of complexity
• God is a very present figure in women's description of protection in displacement, especially those that cross the borders with trochas, as one of or the only protection they have whilst migrating;

(ii) Interviews with key actors (health professionals and decision makers, including those working with the Warao community) Location: São Luís, Maranhão; Boa Vista, Roraima
Like interviews with women and girls, all transcribed interviews are in the shared ReGHID Teams folder. Interviews involved UNHCR Brazil (national scope), UNAIDS and UNFPA, UNHCR representatives in Boa Vista, Roraima state, and other local officials working directly with migrants and the Warao community in São Luís, MA. Unlike those interviews with women, these with key actors are in Portuguese.
The next stage in São Luís is to perform interviews and/or focus groups with Venezuelan indigenous women of the Warao ethnicity. Most, if not all, Venezuelans in the state of Maranhão are Warao. This stage offers some difficulties which are being dealt with by local group:
- Warao groups are not resident in a shelter provided by the local governments, so first contact cannot be mediated by a third party.
- Warao women are especially hard to approach, as before they are allowed/feel free to speak to 'outsiders', they either need the permission of the religious/community leader, called Aidamo, or their husbands, or both.
- Local difficulties involve limited researchers who know Spanish, which reduces communication possibilities, even with the leaders and husbands. Some contact with aidamos has been initiated but it still needs to be further developed.
- Warao women are main providers of 'income' as they sell artisan products or food in the street
Some emerging themes in the interviews conducted with key actors:
• cultural determinants of health and specifically ethnicity as a determinant of (poor) health and of the (poor/inadequate) provision of the right to health of migrants
• ethnic approach in displacement: Warao expected to conform and adjust like migrants, disregard of ethnic and cultural characteristics and rights. Experience of Warao and non-Warao different - Warao difficult to grasp within the model of migration and rights established in Br and in normative frameworks in general
• Warao migrate as a community, role of women in their society marked by reproduction and income provider
• Different experience from non indigenous community, different needs, yet less explored
• Lack of understanding of women's health needs by authorities - difficult access
• Lack of data of all sorts, and of health outcomes - despite studies on HIV prevalence rates in indigenous populations. Also tuberculosis, respiratory problems and infections
• No visiting health services - health services may visit them (but may not respect cultural understandings)
• Systematic blaming behaviour of warao women because of lack of health standards and parenting
• High levels of teenage pregnancy -a continuation of cultural norms, and a result or weakening community cohesion
• barriers: language; cultural barriers; traditions related to health; fear of discrimination; influence of immediate family members, social circle, and other community members; sustaining self-control to the point that trust in available healthcare is established; being discriminated and/or stigmatized by the healthcare provider; receiving inadequate health services to the needs and vulnerabilities of women
• divergent expectations about what the right to health means for health professionals in Brazil and for the Warao indigenous community that affect the ability of healthcare to make a difference in their well-being. This divergency manifests as a dynamic of resistance to/ denial of cultural sensitive healthcare that is in itself a barrier to access to healthcare and to the exercise of the right to health by displaced indigenous populations.
• blame the Warao for their lack of adaptation to the humanitarian assistance provided, for not using health systems- for example, FESMA nurse, said the Warao "have no understanding of health as we do. Criminalisation of the population - and mothers for neglect helath and safety of children
• bureaucratic barriers and lack of a healthcare card are obstacles for healthcare access
• inadequate housing policy
• the Warao are not "indigenous enough" to be awarded equal or similar treatment as indigenous Brazilians, while at the same time being "too indigenous" for established policies for migrants. They were at a crossroads: no existing categories were entirely able to capture them in a way that would be translated in culturally sensitive rights provision.
• Like all other women /adolescent migrants, long-term policies and approaches are absent and policies and interventions seem as emergency actions

Preliminary findings from the research involving the Mesoamerican migration corridor (from Central America to Mexico):
The migratory journey

• Reasons for emigration: Most women left their country due to threats and extortion by gangs, gender-based violence, and to improve their socio-economic situation. Chimumi's team noted that some women interviewed may be suffering gender-based violence - physical and economic -from their partner in Tapachula.
• All of the women interviewed, with the exception of a few who did not specify, crossed the Guatemala-Mexico border by raft. They must carry enough money to pay for the mobilization during their trip: transport from their countries of origin, the raft to cross the river and the trucks to travel to the interior of Tapachula/Chiapas.
• The journey of Central American women to Mexico is short: it lasts between 1 or 3 days in total, depending on the country of departure/origin.
• The interviewed women completed their immigration process - humanitarian visa application - at the Mexican Commission for Refugee Aid (COMAR) in Tapachula town. Until a few days ago, migrants had to wait for the final decision of their application in the city where they had requested asylum; and they could not leave there until they had their documents . Due to the great increase in the flow of migrants in recent years, with the arrival of central American migrant caravans and, in recent months with the arrival of Haitian migrants; and also due to delays caused by the Covid-19 pandemic, the duration of the procedure in COMAR has been extended and is taking several months. Consequently, women that have made humanitarian visa applications and their families settle in Tapachula during that time while they wait for a resolution.
• Most said they reside in rooms they rent with their relatives, friends, or acquaintances. Some of the interviewees have been living in shelters.
• Tapachula is a waiting city and, once they have their documents, they want to migrate to another city in another state that provides them with better employment opportunities, such as Monterrey and Tijuana.
• For women, migration is a strong emotional experience that they are still assimilating, especially when they have left their countries because of violence. Many of the women interviewed cried as they recounted their experiences during the migration journey. One of the factors that most affects them is leaving their families in their country of origin.

Displacement as an SRH determinant

• On the irregular migration route, the continuum of enabling/restricting SRH rights is reconstructed from the point of origin to the return point. Some needs can become even more difficult to meet in the country of transit/destination than when women are in their country of origin. Among these needs, menstrual hygiene stands out (due to the need to have resources to be able to afford products and access adequate spaces and conditions for personal hygiene, including access to places with privacy and drinking water), attention to infectious diseases in reproductive organs (largely due to the lack of adequate clothing for travel, inadequate sanitation services, and exposure to unsafe sexual encounters) and care during pregnancy (not only due to nutritional insufficiencies or lack of timely access to acceptable health infrastructure for the treatment of complications, but also exposure to challenging psycho-emotional situations at this stage). However, there are needs that women can solve more easily, due to the support provided by organisations responsible for responding to the essential SRH needs of the migrant population, such as the identification of sexually transmitted diseases through access to testing and adequate childbirth care (either because they make referrals to the public sector or provide financial support to enable access and payment of private services in cases of emergency). In countries of return, returnee women that are registered with the migration authorities receive information about specialised women's support programmes. There, they can receive comprehensive SRH services, such as Ciudad Mujer (translated as 'Woman City', which is a programme existing in El Salvador and Honduras).
• The migration experience develops so precariously that women give priority to the satisfaction of subsistence needs (food, housing, and transportation) over the needs of preventive health care. They only seek to address their health needs when their illnesses are severe. In the case of SRH, they are contemplated as a subsistence need, so access to long-term contraceptives is prioritised as a strategy to prevent unwanted pregnancies, especially caused by possible sexual assault. This strategy is implemented both when starting the migratory route in the country of origin, and in the country of transit (if necessary). In the case of pregnancies, service providers keep record notes for the follow-up of prenatal controls, but it is difficult to organise them in a timely and adequate manner due to the lack of specialist doctors, reactive materials and equipment required to do laboratory studies and other tests, such as ultrasound scans. The most significant moment during these women's pregnancy is child-birth, which is for them an event that requires assistance in a healthcare centre.
Barriers

• In Mexico, El Salvador and Honduras, women can access basic SRH consultations, but not examinations relevant to a proper diagnosis and treatment, due to the lack of equipment available at the most important points of the migratory route (such as border points). In addition, women must wait for a long-time to have access to specialist medical attention. Once returned, migrant women and adolescents can access public health services available in their community, but within the existing of structural deficiencies.
• Migrant women often travel with little income and do not possess means to finance out-of-pocket health expenses. Obtaining subsistence income in the migration route can occur through taking part in economic activities unsafe to their SRH, due to the prevailing culture of female sexualization (such as working as domestic workers subject to sexual violence by employers, sex workers, waitresses in nightclubs).
• Women traveling with young children have trouble attending their SRH consultations in a timely manner or getting tests for the diagnosis of SRH problems due to the absence of adequate and reliable spaces where they can leave the children. Women usually attend consultations with their sons and daughters. With COVID 19, women go to health care centres less, not only for fear of getting sick themselves, but also their children.
• There are different cultural-religious taboos that prevent women from seeking SRH support services as part of their daily lives and from sharing their problems/needs openly. According to service providers in Mexico, these taboos are more ingrained in the Guatemalan population; and for those in El Salvador, in the rural population. There is still no information on this point with providers in Honduras.
• During the migration route, migrant women can live traumatic experiences (such as different acts of violence, including homicidal violence - especially femicide - and sexual violence) that can prompt women to share details of their migration experiences. They talk with government service providers, and also with other civil providers, about their problems/needs for support.
• In legal terms, irregular immigration status should not be a barrier to access to health services in Mexico. However, migrants have trouble being received in a timely manner and must be accompanied by organisations official representatives to avoid inconveniences.
Although executive decrees have been approved for the universalisation of health provision and, therefore, fare care for migrants and nationals, there are still operational problems to gain access to such services. For the generation of medical care records and follow-up in the public health system, migrant women and adolescents must have an identity document, proof of immigration procedure from COMAR or proof of address, but those who travel irregularly, may lack these or have problems to process them in a timely manner. Organisations (from the civil sector) in the medical area are the only ones that do not require any type of documentation to provide medical care. However, they must always follow the established referral system which means that when referred to the public system, migrant women and adolescents may encounter the documentation barrier again.

• The temporality of the migration project. Migrant women that (although seeking care) leave their health checkups and control unfinished due to their transient condition, which makes them lose all follow-up treatments for diseases and other SRH needs.
• In Mexico, there is a referral route between civil society organizations and medical assistance centres in Tapachula. However, the network is oversubscribed, due to the continuous rise of migrants, but also due to the structural deficiency of financing and health infrastructure in the southern states of the country, such as Chiapas. The needs of all migrant women and adolescents cannot be met. These deficiencies are most obvious in access to specialists, examinations and non-essential medications; and can also have more significant consequences in the pregnancy care and treatment of chronic diseases in reproductive organs.
Exploitation Route Following protocols of data management, the survey and the data collected will also be available for other researchers and fundamentally support national and multilateral policy makers in Central and South America with new data profiling SRH needs of women and girls in displacement from Central America and Venezuela, how those needs are met in places of transit and abode and how met/unmet SRH affect women and adolescent SRH rights, that will inform planning to improve capacity and respond effectively to health needs affected by displacement improving at the same time the prospects of displaced women and girls to be integrated in society, to develop an independent and healthily life.

The methods used and insights gained will also be directly applicable to other ODA recipients facing challenges that displacement pose to the achievement of SDG goals, principally health and gender-related SDG targets, and to respond to conditions of SRH risks of women and girls in Nicaragua, Panama, Dominican Republic, Guyana, Costa Rica, Ecuador and Dominican Republic that are increasingly becoming countries of abode for forced migration in Central America and Venezuela.

IOM is looking into adopting the survey in their programmatic agenda and scale up to other ODA countries that receive migrants in Central America
Sectors Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice

URL http://www.gcrf-reghid.com
 
Description We are strengthening knowledge on SRH needs and rights and supporting a shift towards rights-based health system services through: (i) policy, organisational and practice-related activities; (ii) public engagement and outreach; (iii) dissemination of findings Policy, organisational and practice-related changes within UN agencies and regional organisations: Our research is making a direct impact within the work of UN agency International Organisation for Migration (IOM) operating in countries of transit and (re)settlement for displaced women and girls from Honduras, Guatemala and El Salvador through the joint implementation of a survey, co-produced by Southampton researchers and IOM staff. For the implementation of the tool, Southampton PI and co-is led a training and capacity building sessions for IOM staff in Honduras and El Salvador in February 2022. The survey was taken up by IOM staff and implemented in reception centres hosting migrant women and adolescent girls. IOM is currently working with Southampton researchers to scale up the survey to other reception centres in the region. These activities are designed to be co-created and integrated into the routine work of IOM. ReGHID researchers are also building on established relationships with in-country organisations, such as Médecins Sans Frontières/Doctors without Borders (MSF) in Mexico, Brazilian Association for Collective Health (ABRASCO) in Brazil, International Organisation for Migration (IOM in El Salvador, and Honduras; and the Council of Ministries of Health of Central America (COMISCA) and local Ministries of Health. These organisations co-participate in dissemination and impact activities to embed ReGHID's research directly into their activities. In the first year of the project we have been collaborating in webinars and online interviews with migration-focused NGOs, grassroots organisation and health providers to disseminate information briefs and preliminary findings of research. In the second year, we used the results of interviews and focus groups with migrant women and girls to develop an information guide that will be used as part of peer education activities led by migrants teaching other migrants (from Venezuela in Colombia). The information guide is called AGAPE guide and has been developed together with migrant women in series of workshops. Partnerships with MSF, UNFPA, ABRASCO, the Central American NGO IPAS have been consolidated through activities such as two online event/workshops and a in person stakeholder meeting in Bogota in March 2022 Other findings have been used in journal articles and short pieces and blogs published in high profile outlets such as The Lancet Migration and Open Democracy.
First Year Of Impact 2020
Sector Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice
Impact Types Societal,Policy & public services

 
Description Training of IOM personnel to implement survey on SRH of migrant and returnee women in Central America
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact Feedback on training and pilot IoM staff Acquired learning In general, it allowed them to incorporate new knowledge, identify situations of vulnerability and put it into practice during the application of the questionnaire. Specifically, they expressed that they were able to incorporate the following learnings: • Identifying vulnerable groups in the migration process and how to formulate preventive and action strategies for women in return- Irma Orellana/Psycho-emotional support • Mainstreaming gender in IOM Honduras projects, now under discussion with other heads of office - Rudy Martínez-Information Assistant • Learn Psychological First Aid (PAS) for "self-care", identify situation of discomfort and apply stabilisation strategies in the presence of crisis during/before/after applying the ReGHID questionnaire- Cindy Rivera-Team Leader • Everyone said they learned to use the KoBO collect version (android app version for cell phone and tablet). Until now they had only handled the web version • Empowerment of the ReGHID objectives and approach to the interview, giving the possibility of women to express their experiences during migration- Cindy Rivera- Team Leader There was a general agreement that the training aided in getting the participants to realise the importance of SRH amongst migrants and how this should be incorporated in the reception centres and generally.
 
Description influence on public (with a focus on migrant women from Venezuela)
Geographic Reach South America 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
Impact The guide is a tool for migrants to support other migrants in peer education sessions (organised / hosted by migrant support NGO such as Procrear) to strengthen the knowledge of sexual and reproductive rights of migrant women and girls in Colombia, and information on routes of attention and social services for access to healthcare in relation to SRH. The guide provides specific information about: menstruation, hygiene and management of menstrual pain Questions about knowledge in sexually transmitted diseases Identification of symptoms of sexually transmitted diseases Identification of contraceptive methods and family planning Knowledge about rights and care about abortion, pregnancy, prenatal care Knowledge about birth and postpartum rights, amongst other SRH risks and rights of displaced women and girls. Overall the expectation is that enhanced knowledge can improve self care practices, steam and trust, access to healthcare through health seeking behaviour.
 
Description Exploring Gender-Based Violence Among Displaced Migrant Women from Venezuela and El Salvador
Amount £100,460 (GBP)
Funding ID NIF23\100829 
Organisation The British Academy 
Sector Academic/University
Country United Kingdom
Start 02/2021 
End 02/2023
 
Title ReGHID Questionnaire for Central American women and adolescent girls returnees in El Salvador, Guatemala and Honduras 
Description This questionnaire aims to identify the effects of migration on the Sexual and Reproductive Health (SRH) of adolescent girls and women in situations of forced and prolonged displacement in Central America. This study is framed in ReGHID Project led by the University of Southampton in collaboration with the International Organization for Migration (IOM). The information collected in this questionnaire is anonymized and its use will allow the development of basic indicators and relevant information for evaluation and follow up Policies in Sexual and Reproductive Health during displacement. Below are detailed each of the modules that make up the questionnaire that approaches migratory journey characteristics and the situations associated with SRH during displacement of women and adolescent girl migrants from three Central American countries: El Salvador, Honduras and Guatemala. The questionnaire is divided into the following twelve (12) modules: 1 Geographical identification 2) Migratory Journey 3 Women's health 4) Reproductive history 5) Prenatal and postnatal care 6) Childbirth and postpartum 7) Discrimination and violence 8 Health-related lifestyles 9) Access to services 10) Education and employment 11) State of Health 12) Shelters and detention/deportation centres 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2022 
Provided To Others? No  
Impact A pilot survey was implemented by IOM staff, after a three days training session led by investigators from the University of Southampton, and aided in getting the participants to realise the importance of SRH amongst migrants and how this should be incorporated in the reception centres and generally. IOM is currently working with University of Southampton and reception centres to implement the full scale survey in different centres across the three countries. 
URL https://ee.kobotoolbox.org/x/stvTPq3A
 
Title Survey to identify SRH needs and status, healthcare access and barriers experienced by Venezuelan migrants during migration and in Brazil as host community 
Description Questionnaire for structured interview of migrant Venezuelan women who arrived in Brazil in the last 3 years. The questionnaire was designed specifically for this work in order to assess the impact of forced migration on the sexual and reproductive health of this population. In addition, we sought to use information that was comparable with other national surveys in Brazil and Venezuela in order to enable analysis comparing migrants with women who remained in Venezuela and with Brazilian women in relation to health indicators and access to/use of health services. The questionnaire included modules on the following topics: • Identification of the woman • Migration • Work and income • Expenses • Habits and Lifestyle • Use of health services • Women's Health • Reproductive History • Prenatal • childbirth • Premature fetal loss 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2021 
Provided To Others? No  
Impact Survey was implemented to 1700 migrant women and adolescent girls from Venezuela in Roraima, Brazil, in 2021. Fiocruz Foundation (co-I) led the implementation after training 14 women, from Fiocruz and volunteers from a migrant-based NGO, Hermanitos, to conduct the interviews. The training included information on how to use the REDCAP software used to collect research data, as well as aspects of data quality to generate valid and reliable knowledge, interview techniques and research ethics. Results of the survey will inform policy and advocacy at two levels: National and State/Municipal. It will include the two largest cities in Northern Brazil with the largest number of Venezuelan migrants, Manaus in Amazonas and Boa Vista in Roraima. It includes presentations for legislative and executive members and also for Multilateral Organizations, NGOs and Society in general, with particular emphasis on the health sector. In addition, press and policy briefs will be prepared with recommendations based on the results obtained in the survey. A meeting in Brazil will be held May 2022 in Fiocruz Manaus to plan and discuss strategies with stakeholders and key actos for implementing advocacy actions. 
 
Description Implementing survey on SRH of Venezuelan migrant women and girls in Roraima, Brazil in collaboration with Fiocruz Foundation Manaus 
Organisation Oswaldo Cruz Foundation (Fiocruz)
Country Brazil 
Sector Public 
PI Contribution Fiocruz / Manaus provided support for logistics related to the implementation of a survey that ReGHID conducted in Roraima, Brazil, in migrants shelters. This collaboration entails ReGHID team (Fiocruz/Rio de Janairo, co-I) training personnel from Manaus to conduct the pilot survey with the women in the shelters. Fiocruz Manaus has also provided logistics to work in interviews and focus groups with migrant women and girls. Results of the survey and the qualitative analysis will be presented in the shelters and in Fiocruz host of a policy/impact event, in Roraima (Brazil) in May 2022. The results of the survey and its methodology was used to develop a survey to be implemented in other ODA countries from Central America (El Salvador, and Honduras) in collaboration with the International Organisation for Migration/El Salvador in February 2022, as explained in another entry in the platform.
Collaborator Contribution Fiocruz Rio de Janeiro (co-I) conducted a survey with migrant women from Venezuela in selected shelters in Roraima, Fiocruz Foundation/Manaus offered logistics to be able to access to the shelters and contacts to present the results at a policy relevant event in its office in Roraima.
Impact the main outcome has been the collaboration in the design and implementation of the survey, gaining access to migrant shelters and other relevant organisations that host migrants who were participants in the survey. The survey is a key tool to provide new data on SRH needs of Venezuelan displaced women and adolescent girls and analysis of SRH status alongside analysis of met and unmet SRH health and rights.
Start Year 2020
 
Description Training and capacity building activities developed by the project for IOM staff who piloted a survey on SRH migrant women and girls in Honduras 
Organisation International Organization for Migration
Country Switzerland 
Sector Charity/Non Profit 
PI Contribution PI and co-I at Southampton University have collaborated with IOM personnel based in El Salvador and Honduras, who work directly on the ground with women and adolescent girls migrants from Central America, and returnees, in the co-production of a survey that allows collecting innovative data on the needs, status, challenges and barriers of sexual and reproductive health of migrants as a consequence of the migratory journey. The survey is a 2 module novel tool that has direct contribution to the programmatic agenda of the IOM and provides data necessary to their programmes. Southampton team developed training material, and digitalised the survey, then trained IOM personnel (February 2022) and co-led a pilot of the survey implemented at migrant reception centres in Honduras where IOM staff conducted the survey to migrant women. The pilot took place in two reception centres and will be fully implemented in April 2022 to more migrant women in reception centres in Honduras and El Salvador
Collaborator Contribution IOM facilitated the access to the reception centres, offered suggestions and feedback in the design of the survey, provided suggestions after the pilot for strengthening training and the survey tool. They selected personnel to be trained and will provide further personnel for the implementation of the full survey in Honduras and El Salvador and co-produce analysis of data.
Impact training material for survey implementation survey (digitalised in common platform) protocols for the implementation of pilot of survey in Honduras and for the full implementation of survey in Honduras and El Salvador
Start Year 2022
 
Description Dignity for Women 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Blog entry requested by the Fabian Society, based on the work done on the project and expertise of the PI
Year(s) Of Engagement Activity 2021
URL https://fabians.org.uk/dignity-for-women/
 
Description Displaced women and girls in Latin America threatened by COVID-19 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact blog entry, investigation in Open Democracy. As part of the project on Redressing Gendered Health Inequalities of Displaced Women and Girls in Contexts of Protracted Crisis in Central and South America (REGHID), Pia Riggirozzi, Jean Grugel, and Natalia Cintra explored the way Covid-19 is exacerbating failures in the protection of women migrants' right to health in Central and South America.
Year(s) Of Engagement Activity 2020
URL https://www.opendemocracy.net/en/democraciaabierta/displaced-women-and-girls-latin-america-threatene...
 
Description FLACSO Honduras webinar series 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact The series of webinars organised by our co-investigators at FLACSO Honduras got off to a great start on the 24th of September 2020. Pia Riggirozzi, ReGHID Principal investigator, opened the first session where experts in the field shared their insights about the challenges posed by the feminization of migration flows in northern Mesoamerica
Year(s) Of Engagement Activity 2020
URL https://www.facebook.com/watch/live/?v=358689768815780&ref=watch_permalink
 
Description IGDC Covid-19 Webinar Series Migrants and Refugees Facing COVID-19: UK and Global Concerns 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Event details
Covid-19 is having a devastating impact across the world and on the most vulnerable.

Sara de Jong chairs a panel discussion to explore the impact of Covid-19 on refugees and those engaging in cross-continental migration. This workshop will explore these questions from the viewpoints of six expert speakers from NGOs, activism and academia whose work engages with migrants' rights.

Our speakers will focus on the types of response measures that are likely to be implemented by different actors (governments, non-government) to address migration and refugees trends. The panel will also discuss how these are likely to change as countries move from Covid-19 emergency response to recovery, as well as the fundamental principles that should be maintained to ensure they uphold the rights of migrants and refugees.

This webinar is organised in collaboration with MigNet

Emily Arnold-Fernandez, Founder and Executive Director of Asylum Access, USA
Niamh Ni Bhriain, Programme Coordinator War and Pacification, TNI, The Netherlands
John Grayson, Independent researcher and adult educator, South Yorkshire Migration and Asylum Action Group, UK
Dr Adriana Marcela Velasquez Morales, Researcher at the Latin American Faculty of Social Sciences- FLACSO, Honduras
Dr Pia Riggirozzi, Professor of Global Politics, University of Southampton, UK
Chair:
Dr Sara De Jong, Department of Politics, University of York.
Year(s) Of Engagement Activity 2020
URL https://www.youtube.com/watch?v=Yzo6YV9ZK-0
 
Description Photography Exhibition Showcasing Pictures Taken During ReGHID Fieldwork Activities 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Bruna Curcio, a photographer based in Manaus and a collaborator of the ReGHID project, won third place in a photo competition organised by the University of Manchester, in May 2021. The photographs were taken between June and October 2021 and showcase some of the indigenous (Warao) and non-indigenous women and adolescent girls who had migrated from Venezuela and were residing in Manaus Brazil, at the time the photographs were taken. As part of a decolonising process, participatory methodologies.
The organisers of the competition invited Bruna to a public event to present the photographs taken during ReGHID fieldwork activities in Boa Vista, Roraima in February 2020.
The photos were also featured in a visual project called "La migración y los desafíos de la salud sexual y reproductiva de las mujeres venezolanas desplazadas: Fotovoz como metodología descolonizadora" in collaboration with the University of Manchester.
Year(s) Of Engagement Activity 2022
URL https://narrativasvisuales.com/2022/01/27/la-migracion-y-los-desafios-de-la-salud-sexual-y-reproduct...
 
Description Protecting Migrants or Reversing Migration? COVID-19 and the risks of a protracted crisis in Latin America 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact As part of the Lancet Migration series on Migration and Health, this short piece was commissioned for the SITUATIONAL BRIEF SERIES. Our piece offers a perspective on migrant's rights to health in Latin America during COVID-19, based on background analysis conducted by ReGHID.
Year(s) Of Engagement Activity 2020
URL https://1bec58c3-8dcb-46b0-bb2a-fd4addf0b29a.filesusr.com/ugd/188e74_543cbb0400824084abcea99479dfa12...
 
Description ReGHID project meeting and impact event, Mach 2022 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact A three day event was organised in Universidad de los Andes, School of Public Health, to present preliminary findings and progress of the project and a Ione day discussion of impact with members of the Advisory Board and guests from UNFPA, MSF and IPAS/Centro America.
Year(s) Of Engagement Activity 2022
 
Description Training session for IOM personnel on ReGHID objectives, vision and pilot survey 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Training IOM staff about content of survey, modalities of implmentation, discussion about incorporating the survey in the IOM programmatic agenda.
Sharing ReGHID Project with the staff of the reception centers for the dissemination/incorporation of the survey into the migratory process with the returned women in the centers
Share with the reception centers self-care techniques, guides oriented to the approach of vulnerable groups (respecting their rights),
The three reception centres visited have agreed to participate in the implementation of the ReGHID survey.
Year(s) Of Engagement Activity 2022
 
Description Venezuela, Dispersed: Interdisciplinary Perspectives on Venezuelan Migration and the Diaspora' 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Tallullah Lines, and Jean Grugel, (Co-Is from the University of York) together with Pia Riggirozzi, Natalia Cintra (PI and Research Fellow at the University of Southampton) had been accepted to do a panel presentation at an event organised by the University of Exter, in May 2022. The presentation is entitled''Venezuela, Dispersed: Interdisciplinary Perspectives on Venezuelan Migration and the Diaspora' and discusses the issue of Venezuelan women and girls migrating to other Latin American countries, fleeing hunger, violence, poverty and health insecurities.
Year(s) Of Engagement Activity 2021
 
Description Virtual project meeting with all co-I and Advisory Board 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact ReGHID's general project meeting took place virtually on 9th September 2021. Our international partners from the UK, Brazil, Colombia and Central America showcased the progress that had been made across the board. Investigators presented and discussed mixed methodologies for data collection and analysis, use of quantitative and qualitative methods, including participatory research through photovoice activities with migrant women and girls. The meeting was an opportunity to share and discuss preliminary findings, and next steps.
o-Is from Fiocruz and York University reported on the successful roll-out of a survey that captures health status of Venezuelan women and girls migrants as they embarked in their journeys to when they arrive in Brazil. The survey allows testing how displacement is a determinant of sexual and reproductive health (SRH) needs and rights of women and girls; and the opportunities for displaced women and adolescent girls to act upon information for developing coping mechanisms and improving conditions for socioeconomic wellbeing. This is complementary to the intensive fieldwork conducted by partners at the Maranhão and the Southampton team who made remarkable progress in interviewing migrant women and adolescents - including indigenous Warao women - and health and migration authorities. This work will be further enhanced by the ongoing photovoice methodology which provides migrant women and adolescents with a 'voice' , shedding new light on the intersecting injustices that affect their reproductive and sexual health and rights (SSRH) and access to corresponding services.

Co-Is from Los Andes University in Colombia presented progress of their work that is based on modelling appropriate and responsive health systems in the face of the challenges identified, and what we called the AGAPE guide, which is co-produced with migrant women from Venezuela in Colombia to develop information that is relevant to migrant women and girls regarding SRH. Their work has been based on qualitative and participatory research and that they had successfully completed the first stage of focus groups and interviews with Venezuelan migrant women in Colombia.

The meeting was also followed by presentations by the teams at FLACSO El Salvador and the quantitative team in Southampton leading interviews with migrant women and girls in a different corridor of migration in Mesoamerica, focusing on the flow from Central America to Mexico. There, with the support of Fundación CHIMUMI, the team has been conducting interviews and testing a survey that will be implemented soon with the support of IOM in El Salvador.
Year(s) Of Engagement Activity 2021