The Migration Experience and Differential Risks to Sexual and Reproductive Health in Ghana

Design

An exploratory qualitative study using semistructured interviews among migrant market workers (n = 20) and market leaders (n = 4) working in Agbogbloshie, an informal settlement in Accra, Ghana, was completed in April 2018. Data were collected by trained field staff hired through the Regional Institute for Population Studies at the University of Ghana. Field staff were matched to respondents by gender and were fluent in the languages used in northern and southern Ghana (Twi, Dagbani, and Hausa). Interviewers were trained in the consent and interview methods and completed a pilot study in a neighboring market to ensure the instrument was culturally appropriate and valid. Migrant interview domains included expectations of migration, current working and living conditions, sexual and reproductive health, access to health care, and self-reported health status. The questions that asked about expectations of migration included “Why did you migrate?” and “What were your expectations before coming to Accra?” Questions regarding current working and living conditions included “Tell me about your life in Accra,” with probes for accommodation, food, income; “Tell me about your biggest challenges (problems) since migrating”; and “Tell me about your biggest successes (positive experiences) since migrating.” The main questions on sexual and reproductive health included “Tell me about your first sexual encounter”; “Describe your relationship with your spouse/partner(s),” with probes for who makes decisions regarding money, sex, work; and “How do you plan your childbearing with your partner(s)?” The question on access to health care was “How do you usually access health services?” Finally, the question on self-reported health status was “What is your biggest health concern?”

Interview domains for market leaders included market structure (“Please explain the organizational structure of market work.”), demographics of the market workforce (“Where do most of your workers come from?”), and major health concerns of the market workforce (“What are the most common health issues you notice of market workers?”). Interviewers were told the areas of the interview where prompts should be conducted. The ethical review boards in the United States, Pennsylvania State University, and in Ghana, University of Ghana, approved this study.

Data Collection

Migrant participants were purposively sampled for an equal gender balance (10 males and 10 females) and a wide range of ages (18–64 years) to capture variation in experiences. Migrants were identified for participation using the snowball sampling methodology. Market leaders were asked to introduce field staff to migrant workers, and migrant workers were asked to introduce field staff to other migrant workers. Four market leaders were interviewed to gain a more detailed understanding of the market structure through the leadership and gain their perspective on the health of their workforce. Furthermore, market leaders were essential to respectfully gain entry into the market community for data collection and to approach workers in the market to interview. The two male (aged 51 and 59 years) and two female (aged 55 and 64 years) market leaders were identified by a community resident, hired as a mobilizer.

Study participants were recruited at the market during the day to ensure that a large number of people were available for enrollment. Field staff approached potential study participants to explain the study and if the individual was interested, they were consented and interviewed at that time. The field staff offered to move to a private location for the interview, but some participants preferred to continue working throughout the interview. Interviews lasted 30 minutes on average.

Data Analysis

Interviews were audio recorded in the local language and transcribed in English. The English transcripts constituted the study data. Qualitative data were analyzed using a combination of inductive and deductive coding in MAXQDA (Fereday & Muir-Cochrane, 2006; Ryan & Bernard, 2000). Transcripts were coded by two of the authors. First, the transcripts were read and reread, while being coded for structural (deductive) themes, based on the interview guide. Next, investigators noted initial emerging codes inductively, which were then grouped into themes and reviewed across the data set. Key themes were identified if they were common throughout the data or if particular information related to migration, social support, and structural risks to sexual and reproductive health was disclosed.

Sexual and Reproductive Health

To explore health challenges related to behaviors that could increase negative sexual and reproductive health outcomes, participants were asked to discuss their use of condoms, knowledge of STIs, and experience or knowledge of sexual assault occurring in the community. Although several respondents reported knowledge of condoms to prevent transmission of STIs and unintended pregnancy, many respondents reported low condom use. Fidelity was mentioned by both males and females as the primary way to protect against HIV and other STIs. One male migrant stated,

I have heard of it [the condom] but I have never used it because I don’t sleep with girls outside [of marriage]. (Male, age 36 years)

Furthermore, data suggested that the decision to engage in sexual activity and the use of condoms was decided primarily by the male partner as reported by most respondents of both genders. Sexual coercion and assault were reported among the study population. One female respondent reported her first sexual encounter was a sexual assault,

It was a grown-up man who normally sends me to buy him things. He sent me one day, when I came he gave me a drink not knowing that he drugged the drink so after taking it he raped me. When I woke up, I realized something had happened to me, so I complained to one woman in our house and she followed him and he pleaded that we should forgive him . . . I was 15 at the time. (Female, age 20 years)

A male reported perpetrating sexual assault,

I have also tried to coerce a girl here once . . . She is from the north and she came to work here, that day it was late and she had no place to lie so I took her in and later at night I did it without her consent. I really regretted that action. (Male, age 40 years)

In the scenario described by the male migrant, he took advantage of the fact that a woman did not have a place to live, which is a common situation in the area. Other study participants reported an awareness of sexual assault in the market with younger migrant women being particularly vulnerable.

Yes. It [sexual assault] happens here mostly to the young girls who are from elsewhere, but I don’t know their tribe and it is mostly done by the mate and trotro [minibus] drivers. When they do that and are caught we try to warn and advise them, but they are not arrested. (Male, age 48 years)

Furthermore, sexual coercion was mentioned in describing sexual encounters that were thought to be consensual. However, the comments tended to normalize coercion.

The first time I had sex was with my partner and it was so painful. I didn’t want to do, but he persuaded me into doing it. (Female, age 24 years)

Among study respondents, low condom use, decisions regarding engaging in sexual activity favoring males, the sexual assault of young women from the north, and normalized sexual coercions were all reported negative sexual and reproductive health outcomes.

Perceptions of Migration

Many of the participants reflected on the hopefulness that imbued their decision to migrate. As with most life decisions, the details were varied and complex. A few women reported moving as a result of their husband moving and they were expected to follow. The majority of migrants reported a perceived economic benefit of migrating to Accra as a driving force in their decision to migrate. One woman said,

I came here because of work. I know when I come I will get better things to do. (Female, age 35 years)

However, others reported migrating because it seemed exciting or because they were inspired by the new perspectives with which the return migrants came home. One male reported,

The time I decided to come here I was young and the reason I decided to come is because of the feeling I get when I see those who left for Accra in town. I enjoy that feeling. (Male, age 36 years)

Finally, a female reflected on her migration to Accra as an experience that positively changed her perspective,

For my life, my eyes didn’t open at the north; my eyes opened here in Accra. (Female, age 27 years)

These intangible reasons to migrate including excitement, adventure, and new experience were expressed through these young migrants.

The migrant experience is complex, and migrants report mixed feelings about their decision to migrate. Many migrants reported feeling that migration has been more difficult than originally was imagined, as one female reported,

Not everyone is born with a silver spoon in the mouth, but we thank God for we get what we eat. (Female, age 50 years)

Coming from poverty in rural areas to living in poverty in Accra presents challenges related to low income and high cost of living where even access to food can be a concern. Even with the challenges that exist in Agbogbloshie, migrants stayed because it was better than returning home,

Things are not going on well with me here, but there is no alternative. Because back at home, things are worse, that is why I am still here managing little by little. (Female, age 20 years)

While many migrants reported regret or hardship related to migrating, some reported the realization of a goal shown through this statement,

My life here is okay. Because I have a business even though it doesn’t move like before but it is still better than working for someone. My husband and I rented a room, for food too I sell, so life here, I will say I thank God. (Female, age 35 years)

This participant was able to become a business owner, which few are able to accomplish.

Working and Living Conditions

Agbogbloshie is a vibrant area in central Accra. While it mainly functions as a wholesale market, distributing produce to other centers across the country, it is also a residential district, the site of one of the largest e-waste dumps in the world (Srigboh et al., 2016), and a hub for those migrating to Accra from other areas in Ghana. Agbogbloshie is both chaotic and highly organized, with each market area dedicated to a separate type of produce and governed by a strict hierarchy of leaders and “queens” and vendor organizations. All of those interviewed in this study work in Agbogbloshie and most also call it home.

Market leaders describe the market as a difficult place to work due to physically demanding jobs, long hours, and low pay. The positions and leadership are highly gendered and hierarchical. Young women, particularly migrants, frequently take jobs as kayaye, or head porters. Head porters carry large containers to assist market customers and carry their wares. It is lower paying than vendor work, frequently marginalized, and lacking in protections of vendor organizations. Men are more likely to work in the scrap business, disassembling machinery or electronics to sell piecemeal. As one of the male market leaders explained,

The migrants, they come with a purpose. Most of them, because of the life there [in the rural area], the mature and the young, when they come here, they work to make money and save, but the difficulties they also face are there [in the rural area]. (Male, age 59 years)

He went on to describe the brutal process of migration, in instances where “agents” transport large groups of people to Accra, demanding money and making promises of a better economic life. He was sympathetic to migrants and the challenges of trying to save money while in a cycle of debt and poverty and concluded,

It is more or less like slavery. (Male, age 59 years)

The combination of market hierarchy and migrant vulnerability was described as exploitative, as migrants were described to have few avenues to improve their livelihood.

For migrants, it can be challenging to enter the formal market structure in Agbogbloshie. Typically, getting a job and being successful requires knowing the right people and keeping those people happy. One of the older female market leaders described the long process to get to where she is today, working for more than a decade under a market queen who took her on as a “daughter.” Only after she paid her dues, she became a leader and was given a few people to manage. Another market leader explained that relationships are central to the hierarchy,

Here we have leaders so before you can come here you must know someone. You only come if you know someone here. And we come to the market to sell in turns if it’s not your turn you will not be allowed to sell that day at all. (Female, age 55 years)

Due to long working hours, low incomes, and a paucity of affordable housing options, many migrants face challenges in finding decent and safe accommodation. For some, this concern is nagging and pervasive,

The challenge I faced since coming to Accra is accommodation. Every time even if you are eating you think about your rent so that is a serious challenge for me. (Male, age 43 years)

As mentioned above, Agbogbloshie has both commercial and residential areas, often with blurred lines between the two. One man told us that he prioritized saving money to send home for so long that he was unable to pay for a place to stay, saying

When I came, I slept outside for 9 years. (Male, age 45 years)

While his case is extreme, it is common for migrants to use their market stalls as a place to live. They sleep in the small areas where they work to save money from additional rent, to protect their wares, and to be ahead of others when early deliveries arrive. One young man explained,

I have not rented a room, I sleep here [in the market] but I kept my things in my brother’s room. But here, if you are to be sleeping at home, you won’t get work to do because the trucks come early around 1:00 am or 2:00 am unless you have someone who can inform you whenever the cars are in. (Male, age 29 years)

Men are not the only ones who sleep inside the market, though women face additional concerns of safety when sleeping in such an exposed place. One female reported sleeping in the market,

The market is not good. For accommodation this [market stall] is where I sleep. The man who brought you here gave me this place to be staying, and for food, it is not a problem because I sell food. I know this place that we are sleeping is too small for us but because this is where I work we are managing it here like that. (Female, age 50 years)

A man explained that sleeping outside may be a risk factor for sexual assault,

The victims are the migrants, mostly the northern migrants and it is because they don’t have a place to sleep. (Male, age 22 years)

The lack of safe accommodation in Agbogbloshie is a prevalent concern and likely contributes to a number of poor health outcomes.

Isolation and Social Support

Perhaps unsurprisingly, many migrants described a sense of isolation in their life in Accra. Eight reported having no friends whatsoever in Accra, and six of these were women. The primary reason that women gave for not having friendships was time. As one woman summed up,

Me, I don’t have friends here because I don’t have time here to waste. (Female, age 44 years)

Others cited barriers in communication with people from different areas of Ghana and the friends they do have often come from the same region in Ghana. While some migrants who were interviewed did not report any friendships in their new environment, overall migrants recognized the importance of friendships and benefits of having a social support network in their new home. Some even explicitly linked poor social support to their own poor mental health. Those who have been successful in building friendships and support networks described strategies of seeking out others through sports and other community organizations when they have time. One man even went so far as to change his religion after migrating, saying,

Because, you know in the north, we have a religion we were following but when you come to a place where you need help from someone, you understand, so now I am a Christian. (Male, age 43 years)

He was able to find both friendship and support in this new community. Worry related to the interconnectedness between social support and health was also evident. A female described her reality if she falls ill,

What I fear I will face is sickness, if I fall sick here I don’t know what will become of me. (Female, age 19 years)

The combination of low social support and poor health, which may become a vicious circle, was an expressed concern in this community.

Access to Health Care

Many respondents reported accessing health care through pharmacies, clinics, and hospitals. About half reported not having current health insurance. Most migrants were enrolled in the National Health Insurance Scheme in the past, but their insurance expired. The participants did not express any major barriers to accessing care. Younger people tended to report fewer health problems and less need to access services; however, no participants reported accessing services when well. One young male reported,

The first point of call is the drug store, but if it persists we then proceed to the hospital. (Male, age 22 years)

A younger female reported,

I will buy drugs and take [them]; if there is no change I will go to the hospital. (Female, age 19 years)

The older population in this study who had chronic conditions reported accessing health care to manage the condition. An older migrant reported,

Anytime I am sick, I visit the hospital for a proper check-up because of my high blood pressure. (Female, age 50 years)

Additionally, while several respondents reported accessing health care through hospitals or clinics, others reported accessing health care through the pharmacy or clinics that do not subscribe to the National Health Insurance Scheme.

Limitations

This study has several limitations. First, due to the response bias inherent in snowball sampling methodology and because those who consented had the time to participate in the study, the most vulnerable migrants may have been missed. It is possible that migrants suffering from more difficult work situations or violence were less likely to participate in this study. Second, engaging migrant market workers in their workplace may have introduced a possible respondent bias as workers may have been less likely to share negative experiences especially about their working conditions or their sexual and reproductive health when in the market. Third, some of the interview questions asked about previous events such as their migration journey and reproductive lives. These questions may have been affected by recall bias from the respondents. Finally, this research is likely affected by the healthy migrant hypothesis, meaning that migrants who suffer from worse health outcomes may be more likely to travel back home and were therefore not available to participate in this study.

Implications for Policy and Future Directions

This study revealed that the challenges related to maintaining sexual and reproductive health are not only at the individual level but also at the community level and are demonstrated through varied attitudes surrounding migration, poor living and working conditions, low levels of social support, and low reproductive autonomy. The link between expectations of migration, living and working conditions, social support, and sexual and reproductive health should be further explored. Migration status requires a more nuanced definition and migrants hold diverse motivations to leave home, all of which may not be associated with risks to sexual and reproductive health. Migration in Ghana is a key factor in the country’s development. In 2016, Ghana created a National Migration Policy to support migration within the development agenda and to establish social protection policies for migrants in urban areas (Ministry of the Interior, 2016). Due to the protections in place for migrants, there may be increased migration in Ghana and the situation for migrants may improve. However, the risks to sexual and reproductive health outcomes may be less due to migration and more due to gender norms in Ghana and the living and working conditions in the informal settlement. Continued research in this area will add to the broader literature on migration, informal settlements, and health in Ghana and will contribute to the continued development of the country.