Beyond Borders: Exploring the Lived Experiences of International Migrant Women in Nigeria, a Deep Dive into Healthcare Realities and Utilization

doi:10.21203/rs.3.rs-4671466/v1

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Beyond Borders: Exploring the Lived Experiences of International Migrant Women in Nigeria, a Deep Dive into Healthcare Realities and Utilization

https://doi.org/10.21203/rs.3.rs-4671466/v1

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This study explored access to and utilization of healthcare facilities among migrant women in an urban slum community in Nigeria, focusing on factors influencing healthcare-seeking behaviors and the implications for public health interventions. A qualitative case study-oriented research design was employed, involving in-depth interviews with 21 migrant women of reproductive age and 4 key informant interviews with healthcare workers in the Ayobo community of Lagos State, Nigeria. Data collection occurred from June to September 2018, and thematic analysis was used to interpret the findings. Three main themes emerged: living conditions, pattern of healthcare utilization, and factors influencing accessibility and utilization of healthcare facilities. Living conditions were characterized by housing instability, limited access to clean water and sanitation, and financial constraints. Migrant women demonstrated a preference for traditional remedies over formal healthcare due to cultural beliefs and perceived effectiveness. Recommendations from peers and family members influenced healthcare decisions. Targeted public health interventions are needed to address the multifaceted challenges faced by migrant women, including improving housing conditions, providing access to clean water and sanitation, and promoting culturally sensitive healthcare programs.

Gender Studies

Sociology

Health Policy

migrant women

healthcare-seeking behaviors

public health

urban slum

Nigeria

The accessibility and utilization of modern healthcare services pose significant challenges for poor households in Sub-Saharan Africa, particularly in areas where affordable and high-quality healthcare is scarce, and access to health insurance is limited (Ackerson and Zielinksi, 2017; Alam et al., 2015; Kiwanuka et al., 2008). Studies have shown that residents of informal settlements in sub-Saharan Africa, as well as regions in Asia and Latin America, lack access to fundamental social infrastructure including clean water, electricity, well-maintained roads, sanitation facilities, high-quality education, healthcare services, and proper waste management systems (Satterthwaite et al., 2019; Zerbo et al., 2020). In Nigeria, the substantial majority of health expenditure, exceeding 70% of approximate $10 per capita health expenditure, is attributed to private out-of-pocket expenditure (Uzochukwu et al., 2015). Reliance on out-of-pocket expenditure significantly hinders the equitable access to high-quality healthcare services, particularly within urban slum areas (Owusu et al., 2008).

Nigeria, as a third world nation, has been found to have areas characterized by slum settlements (Akinwale et al., 2014; Zubair et al., 2015). Numerous urban residents, unable to afford decent living accommodations due to factors such as the high costs associated with owning their own homes, steep rental prices, and exorbitant expenses related to acquiring urban land, had sought shelter in slums despite their challenging living conditions often likened to a “near-hell-status” (Pat-Mbano & Nwadiaro, 2012: 258). Urbanization often leads to the proliferation of slum areas and a concentration of vulnerable populations within these settlements (Tacoli et al., 2015; Zulu et al., 2011).

In the Lagos megacity of Nigeria, a significant number of migrant women residing in slums belong to lower socioeconomic classes (Akpabio et al., 2021; Badmos et al., 2020). These women migrate to the city with hopes of improving their livelihoods (Owusu et al., 2008). However, limited education, skills, and work experience restrict employment opportunities for migrant women, confining them to low-paying jobs such as construction labor, domestic service, casual factory work, and petty trading (Adeosun et al., 2023). Due to minimal incomes, these women are often compelled to live in slum areas, enduring unsanitary and unhygienic conditions (Corburn & Hildebrand, 2015). They often navigate their daily lives with only the most essential resources and provisions (Soliman, 2023). Even those with some financial means are often reluctant to invest in home improvements due to the temporary nature of their residence or the illegal occupation of public lands, coupled with the constant threat of eviction (Popoola et al., 2020). Thus, the quality of housing in slum areas remains poor (Omole, 2010). The substandard living conditions, characterized by overcrowding, poor sanitation, and occupational hazards, adversely affect the health of slum dwellers (Malik et al., 2020).

Globally, poor women, particularly those in developing countries, exhibit the highest rates of mortality and illness (World Health Organization, 2009). This trend is evident in the health status of women and children in these communities (Fink et al., 2014; Mberu et al., 2016; Unger, 2013). A significant concern is the indifferent attitude of migrant women towards their own health and its management (Dias et al., 2012). They typically seek medical treatment only when health issues cause severe physical discomfort or impede their work performance (Ikechukwu et al., 2020). This neglect exacerbates their health problems and highlights the urgent need for interventions to improve the living and health conditions of migrant women in Lagos slums.

Oftentimes, women in slum areas overlook minor health concerns (Desmond, 2012), and this poses serious implications for their health and well-being. The significance of health as a crucial economic concern for residents of slum areas, particularly women, cannot be overstated. Research has shown that an unhealthy physical environment in slums can lead to illnesses requiring medical attention, resulting in a loss of workdays and economic productivity (Prüss-Ustün et al., 2017). Barua (2014) highlighted that women in slum areas often experience various health issues such as joint pain, mental stress, white discharge, and acute fatigue, with many resorting to self-medication for treatment. These health problems are commonly attributed to factors like excessive workload, inadequate nutrition, and poor living conditions (Abdi et al., 2021; Nangia & Thorat, 2000). Furthermore, studies indicate that slum residents tend to ignore minor ailments and avoid seeking medical help when unwell (Das et al., 2018; Ezeh et al., 2017; van der Heijden et al., 2019). One key factor influencing the healthcare-seeking behavior of slum dwellers is the limited availability of healthcare facilities, leading to reliance on informal providers, and sale of medications at unauthorized outlets (Krishna, 2010; Shukla et al., 2019). In these settings, only a limited range of low-cost medicines is typically accessible, often sold in grocery stores without proper licensing (Goswami, 2014).

Research indicates that the migrant population residing in slums often face challenges in accessing healthcare services (Kusuma et al., 2010). Disparities have been observed in the access and utilization of healthcare services between the general urban population and migrants, with inequities existing in healthcare access (Owusu & Yeboah, 2018; Park et al., 2022). Migrants are typically of lower socioeconomic status, less likely to be employed, and may reside in less secure housing compared to non-migrants (Coates et al., 2013; Owuor, 2007). Many migrant women who relocate to slum areas in search of employment opportunities often have lower levels of education compared to non-migrants (African Population and Health Research Center, 2014). They frequently find themselves economically inactive or engaged in low-wage and irregular employment following migration (Emina et al., 2011). These circumstances can make it difficult for them to provide adequate support for their children due to challenges such as inadequate housing (Gulyani et al., 2012; Meth, 2013), the risk of eviction (Beyer et al., 2016; Gulyani et al., 2012; Meth, 2013), and food insecurity (Faye et al., 2011).

In the bustling community of Ayobo in Nigeria, a diverse population of migrant women navigate a landscape marked by both opportunity and challenge. Drawn by the promise of a better life for themselves and their families, these women grapple with a myriad of issues that impact their daily existence, with access to and utilization of healthcare being a critical determinant of their well-being and quality of life. Limited research exists on healthcare utilization and accessibility among migrant women in Nigerian slums. In order to address this gap, this study drew on a qualitative study to understand the patterns of healthcare utilization and factors influencing accessibility among migrant women in urban slums in Nigeria. The aim of the current study was to examine the level of access to healthcare services and utilization of health facilities in urban slum communities in Nigeria. The study was guided by three research questions:

What are the features of living conditions of international migrant women in urban slums?
What are the patterns of healthcare utilization among migrant women in urban slums?
What are the factors that influence accessibility and utilization of health care facilities by migrant women in urban slums?

The foundation of this study was built upon firsthand field observations and investigations. The research adopted a qualitative case study-oriented research design, focusing on migrant women of reproductive age. The case study design is important for three reasons. First, it allows for a concentrated focus on meticulous and thorough data collection from multiple sources within a specific locale and targeted group (Bryman, 2008). Second, it emphasizes the importance of preserving and analyzing the contextual backdrop, which is crucial for conducting in-depth analyses (Gerring, 2007). Third, it is more valuable compared to research endeavors that seek superficial knowledge from diverse contexts, as it avoids the risk of conceptual stretching (Schutt, 2018).

The study aimed to recruit 25–30 female participants, which was similar to previous qualitative inquiries in relation to healthcare access and utilization among women (Ganle et al., 2014; Ntoimo et al., 2019; Udenigwe et al., 2022). To be included in the study, participants needed to be migrant women of reproductive age who lived in Ayobo community of Lagos State, Nigeria where the study was conducted. Secondary data were utilized through a comprehensive review of pertinent literature, including books, articles, and reputable internet sources.

The study location was Ayobo, a high-density suburban district in Alimosho local government area of Lagos State, south-western Nigeria. Situated at the border of Aiyetoro, Ogun State, Ayobo shares the Local Council Development Area with Ipaja. According to the 2006 census, the population of Ayobo was approximately 633,009 people (National Population Census, 2006). The selection of Ayobo for this study is strategically justified by its diverse migrant population, representative urban slum characteristics, healthcare access challenges, and the influential role of community dynamics (Opoko et al., 2015). These factors collectively provide a robust foundation for exploring the lived experiences of international migrant women and developing informed interventions to enhance their healthcare access and utilization.

Recruitment of participants in this study proved challenging due to factors such as sensitivity, security concerns, and a reluctance to disclose information on research issues. The snowballing technique was employed, involving the identification and contact of initial interviewees who subsequently referred and introduced the research team to additional participants capable of contributing to the research. To mitigate bias and encompass varied perspectives, in-depth interviews were conducted at the household level from June to September 2018.

Semi-structured, audio-recorded interviews lasting ~ 45 min were conducted face-to-face by Authors One and Two. The interview guide used with participants focused on three themes: living conditions in slum settlements, the nature of existing healthcare, and factors that influence accessibility and utilization of healthcare facilities in slum settlements. The interviews with health officers focused on the same topics, however, it was more focused on the challenges facing healthcare utilization and accessibility among migrant women in the study area. Data collection ended when there was sufficient information from the interviews to answer the research questions (Malterud et al., 2016).

The transcripts from the audio recordings of the face-to-face interviews were transcribed by Author One and Author Two. Braun & Clarke's (2021) reflexive thematic analysis framework, consisting of six phases, was employed to interpret and derive themes from the data. This interpretive process took place both during and after data collection. Detailed notes were taken after each interview to capture key topics discussed, and data familiarization was an ongoing process during transcription. Coding and theme development were centered on the research questions. The researchers engaged in regular meetings to discuss data interpretation, theme construction, and the implications of the study findings.

The study included a total of 25 participants, comprising 21 migrant women and 4 healthcare workers. Among the participants, the majority were women, with the exception of one male, the sole Medical Doctor in the study area. Participants' ages ranged from 22 to 48 years. They hailed from Togo, Benin, and Niger - neighboring countries to Nigeria. The duration of residence in the study area varied, with some participants having lived there for many years, while others had only recently moved. The anonymity of all interviewees was carefully maintained throughout the study.

Living Conditions of International Migrant Women

The living conditions of migrant women in impoverished urban slums reflect the challenges posed by inadequate housing, with many residing in makeshift and incomplete buildings that underscore the precarious nature of their accommodation arrangements. Despite facing substandard housing conditions, participants in the study demonstrated resilience and adaptability in navigating these challenges, emphasizing the fundamental importance of having shelter, regardless of its quality. The narrative shared by the following participant shed light on their experience of housing instability and the gradual process of improvement within their living environments:

When I arrived in Nigeria in 2015, I lived in Agege with my husband and his friend. Our living condition was challenging, as we struggled with poor housing and limited resources. However, in 2016, we decided to relocate in search of better opportunities. Since then, we had welcomed three children into our lives. Despite the initial hardships, we are gradually improving our situation. Through perseverance and hard work, we are determined to create a better future for ourselves and our children. — 24-year-old migrant from Benin Republic

Access to clean water emerged as a pressing concern among participants in the study, highlighting the challenges faced by migrant women and their families in securing a reliable water supply. Many reported relying on neighbors or nearby sources to fetch water, often enduring long distances or incurring costs to meet their daily water needs. The following participant described her water-fetching routine, stating that she obtains water from a source located about three houses away from her residence:

I fetch water from a street tap, located about three houses away from my residence. Unfortunately, where I live lacks any facility for water access, leaving us dependent on communal sources for our daily needs. This absence of basic amenities adds an extra burden to our daily lives, requiring us to travel a distance to fulfill a fundamental necessity. Despite these challenges, we persevere, making the journey each day to ensure our family's access to clean water. — 22-year-old migrant from Togo

Another participant, a mother of four, shared her experience of accessing water from a neighbor located in close proximity to her home, as well as getting help from fellow church members:

I fetch water from one of my neighbors close to where I live. Fortunately, she graciously helps me, understanding the challenges we face. Being the wife of a Pastor, I receive support not only from my neighbor but also from fellow church members. During the period of my childbirth, they generously assisted me in fetching water, alleviating some of the burdens of daily life. — 31-year-old migrant from Togo

Access to adequate sanitation facilities posed a significant challenge for participants in this study. Many described using makeshift or communal toilets, often situated within incomplete structures, highlighting the lack of proper sanitation infrastructure in their living environments. Waste disposal methods were also characterized by makeshift practices, with burning being a common strategy employed during dry seasons. However, the arrival of rainy seasons posed additional obstacles to waste management, particularly affecting disposal practices and access to designated refuse dumpsites. For example, the following participant shared insights into their living conditions, expressing concerns about the quality of their toilet facilities:

My toilet situation is less than ideal. It is a source of embarrassment, especially when visitors come around. The makeshift setup within an unfinished building lacks privacy and basic hygiene standards. To manage waste disposal, particularly during dry seasons when the risk of disease is higher, we take precautions by burning our refuse. Despite these challenges, we try our best to maintain cleanliness and sanitation as best as we can under the circumstances. — 41-year-old migrant from Benin Republic

Another participant provided further perspective on sanitation challenges within their living space. She described using a pit latrine shared by all occupants of their “face-me-I-face-you” residence, a specific type of housing in Nigeria where multiple one- or two-room apartments face each other along a common walkway leading to the main entrance of the building:

The toilet is a pit latrine shared by all the occupants of my "face me I face you" house, a common arrangement in our community. However, for the sake of my children's hygiene, we use a potty (chamber pot) for their needs. Currently, there's no proper method for waste disposal. During the dry season, I resort to burning waste, but during the rainy season, disposing of it becomes a significant challenge. Complicating matters further, the land where we used to dump our refuse has been sold to someone planning to build a house there. This leaves us in a difficult situation, grappling with sanitation issues with limited options for waste management. — 30-year-old migrant from Niger Republic

The living conditions observed among migrant women and their families have significant health implications. The prevalence of various ailments was attributed to environmental factors such as stagnant water bodies, poorly maintained surroundings, and inadequate waste management practices. The following key informant emphasized the crucial role of the environment in influencing the prevalence of illnesses within the community:

The environment plays a significant role in the prevalence of certain ailments despite efforts to address them with medication. In our area, the presence of swamps, overgrown bushes, and dirty drainage creates an ideal breeding ground for disease-carrying mosquitoes like the female anopheles. Despite our efforts to counsel the community on the importance of cleanliness and hygiene, the persistence of these environmental factors continues to contribute to the ongoing health challenges we face. — 29-year-old Medical Doctor

Pattern of Healthcare Utilization

A notable trend observed among participants in this study was their preference for traditional remedies, like herbs and consultations with traditional healers and auxiliary nurses, rather than seeking care at formal healthcare facilities. This inclination towards traditional medicine often stemmed from personal beliefs, cultural traditions, and the perceived efficacy of herbal treatments in addressing health issues. Some participants expressed a preference for herbal remedies as a first line of defense against illnesses, saving visits to hospitals or purchasing pharmaceutical drugs for more severe or persistent health concerns:

I prefer starting with herbal remedies initially due to their natural properties and historical effectiveness in treating various ailments. The use of herbs align with my belief in holistic healing and the importance of traditional medicine in maintaining overall well-being. Assessing the severity of the illness is crucial in determining the appropriate course of action, and if the symptoms indicate a serious condition, I am open to purchasing medication or seeking professional medical care at a hospital. While herbs have been my go-to remedy and have provided relief in the past, I acknowledge the importance of timely and comprehensive healthcare interventions in managing severe or persistent health issues. — 36-year-old migrant from Niger Republic

Financial limitations and a lack of awareness regarding the affordability of healthcare services were notable hurdles hindering participants from accessing formal medical care. For example, a Matron who supervises the nursing staff in a health center, highlighted how financial constraints deterred migrant women from seeking care at health centers, perceiving formal healthcare as unaffordable. She also stated a lack of information and knowledge about the cost of services at health facilities fostered misconceptions about healthcare affordability, leading some individuals to spend money on unnecessary medications from chemists (patent medicine vendors) instead of seeking appropriate medical attention:

Financial constraints pose a significant challenge for many individuals in accessing healthcare services. When discussing this issue with them, a common refrain is "owo po lowo mi," a Yoruba saying meaning they lack the funds to afford health center services. The primary obstacle faced by these women is lack of information and knowledge regarding healthcare affordability. The primary challenge for these women lies in their lack of information and knowledge regarding healthcare affordability. Upon engaging them in conversations, they often express surprise upon learning that the health center offers services at minimal or no cost, contrary to their previous beliefs. This lack of awareness leads them to expend funds on unnecessary medications from local chemists, resulting in higher overall expenses. Although the health center typically imposes a nominal fee for services like injections and treatments, individuals may be unaware of these affordable options. Despite financial constraints, the health center is willing to provide subsidies for those in need, underscoring the importance of cost-effective healthcare access. — 48-year-old Matron at the Community HealthCare Center

This study brought to light a prevailing pattern where participants often resort to self-care practices, including buying medications from patent medicine vendors (PMVs), commonly referred to as chemists. However, when it concerned their children, there was a distinct preference for seeking professional medical care at the health center. This preference indicates a heightened level of concern and a proactive approach to safeguarding their children's well-being, as articulated by one participant:

I seldom visit the health center myself. As an adult, I feel confident in managing my own health issues. If traditional remedies don't suffice, I resort to purchasing medications from a chemist. However, when it comes to my children, I consistently prioritize their health. I always take them to the health center to ensure they receive thorough medical attention and accurate diagnoses. Their well-being is my utmost concern, and I place my trust in the health center's services for their treatment and immunizations. — 33-year-old migrant from Togo

Likewise, another participant noted a prevalent pattern among migrant women where their own healthcare needs are frequently relegated to a lower priority compared to ensuring essential healthcare services, such as immunizations, for their children:

The main reason I go there is for my children. I don't see myself as a regular patient at the health center. When I fall ill, I turn to herbs or visit a chemist instead of seeking care at the health center. However, when my children fall sick, I prioritize taking them to the health center to ensure they receive proper diagnoses and treatment. Their well-being is my utmost priority, and I have confidence in the health center's ability to provide the necessary care for them. Additionally, I rely on the health center for their immunizations and other preventive measures crucial for their overall health and well-being. — 36-year-old migrant from Benin

The narratives shared by participants provided insight into the obstacles and perspectives regarding laboratory tests and the availability of prescribed medications at the health center, highlighting a larger concern about limited resources and healthcare infrastructure within the community under study. For instance, one participant noted that a lack of awareness or comprehension regarding the significance of laboratory tests in effectively diagnosing and monitoring health conditions contributed to a hesitancy to undergo such tests, particularly among migrant women who perceived they already grasp the nature of their health issue:

The health center possesses some testing equipment, but I seldom utilize the laboratory facilities. Why should I undergo testing when I already have a good understanding of my children's ailments? I perceive it as unnecessary to undergo testing when the symptoms are familiar, and I can manage them effectively with the treatments I'm accustomed to. Moreover, I believe the time and expense associated with these tests would be better allocated to providing immediate care for my children. — 30-year-old migrant from Benin Republic

Similarly, another participant expressed hesitation about undergoing laboratory tests, citing a mix of factors such as the perceived seriousness of the health concern, apprehension about receiving unfavorable results, and skepticism regarding the healthcare system's capacity to deliver precise diagnoses:

God forbid! Why would I require tests? My issue isn't that grave; I'm solely focused on immunization. I don't concern myself with those laboratory tests because I rely on my intuition for health matters. Moreover, I prioritize preventive actions like immunization over unnecessary tests for minor ailments. — 23-year-old migrant from Niger Republic

In addition to concerns about laboratory testing, participants also highlighted challenges related to access to prescribed medications at the health center. This observation underscores a common issue faced by many individuals in resource-constrained settings, where limited availability of essential medications at healthcare facilities necessitates out-of-pocket expenses to obtain prescribed drugs from external sources:

The health center doesn't dispense medications; rather, they provide prescriptions that we must obtain from chemists and pharmacists independently. This places an additional strain on our already limited resources, requiring us to invest extra time and money in traveling to acquire the prescribed medications. — 28-year-old migrant from Niger

Furthermore, another participant echoed similar sentiments:

I rarely depend on the medications provided at the health center because they're not consistently available. Instead, after diagnosing our conditions, they prescribe treatments, leaving us to procure the necessary medications from a chemist or pharmacy elsewhere. This procedure can be burdensome and exacerbates the difficulties of accessing adequate healthcare. — 26-year-old migrant from Togo

Factors Influencing Accessibility and Utilization of Health Care Facilities

Migrant women exhibit a wide range of perceptions about healthcare personnel, reflecting both positive and negative experiences within the healthcare system. These varying perspectives illuminate the complex dynamics that influence their interactions with healthcare providers and their overall satisfaction with the care received. The following participant, who is a regular visitor to the health center, expressed a sense of contentment with the treatment provided by healthcare personnel:

I can't lie, the health workers treat me well. Even when they scold me, I know it's for my own good. I can tolerate any insult because I need their help and believe it comes from a place of love. Their strictness shows they care about my health and want the best for me. This makes me feel more confident in the care I receive, knowing that they are genuinely invested in my well-being. — 30-year-old migrant from Niger

In addition to the participant who expressed satisfaction with occasional scolding as a form of care and love, another participant highlighted the inconsistency in healthcare services experienced by migrant women. She noted that the provision of treatment often seemed to depend on personal relationships or financial incentives. Her sentiment underscores a critical issue within the healthcare system. The variability in service provision based on personal relationships and financial incentives reflects systemic inequities, which can lead to inconsistent care for migrant women. The reliance on informal exchanges suggests that the healthcare system may lack sufficient resources or structured protocols to ensure fair and timely access to care for all patients, regardless of their socio-economic status or personal connections:

They make an effort, but sometimes you end up waiting a long time. If they like you, they might give you some medication when you're sick. If you have money, you can give them a small reward. It often feels like the quality of care you receive depends more on your personal relationship with the healthcare workers and your ability to provide financial incentives than on your actual medical needs. — 22-year-old migrant from Benin Republic

Distance to healthcare facilities is a crucial factor influencing individuals' utilization of healthcare services. The proximity of health centers can significantly impact the choices people make regarding their healthcare. For instance, a 22-year-old participant highlighted that the distance to the health center influenced her decision to opt for more accessible herbal remedies instead of seeking conventional medical care. This demonstrates how geographical barriers can shape healthcare-seeking behavior, leading individuals to explore alternative options when faced with challenges in accessing traditional healthcare services. On the other hand, 21-year-old participant expressed a contrasting perspective, indicating that the distance to the health center was not a significant concern for them. She viewed walking long distances as a manageable aspect of their daily routine, suggesting a higher threshold for physical exertion or a different perception of accessibility to healthcare services. This divergence in experiences underscores the diverse ways in which individuals navigate and adapt to the challenges posed by geographical barriers in accessing healthcare. It highlights the need for a nuanced understanding of how distance and accessibility influence healthcare-seeking behaviors among different individuals and communities. Addressing these geographical barriers is essential for ensuring equitable access to healthcare services for all residents, particularly those in underserved areas.

Financial constraints represent a significant barrier to accessing healthcare services for migrant women. The inability to afford necessary medications and healthcare services due to financial limitations poses a considerable challenge for those seeking medical treatment. This economic barrier not only impacts the ability to access essential healthcare but also influences the decision-making process regarding alternative healthcare options and coping strategies. The following key informant emphasized the impact of financial issues on healthcare access, noting that in the absence of sufficient funds, individuals often turn to religion or seek out less costly alternatives for managing their health needs:

The financial aspect is the main issue; it hinders a lot of things. They can't afford to buy drugs, and distance and other factors become secondary concerns. They often turn to religion because they lack the necessary finances. Additionally, midwives are cheaper than hospitals, so the choice to seek care from them is driven by cost rather than distance or other logistical issues. — 29-year-old Medical Doctor

Additionally, another participant pointed out that the cost of prescribed medications frequently acts as a deterrent to purchasing them. This observation sheds light on the direct impact of medication costs on treatment adherence and health outcomes, as individuals may forego or delay necessary medications due to financial constraints, potentially compromising their health and well-being. She stated thus:

I buy drugs too, but it depends on the type and cost. If the health center do not have the medications, we have to purchase the prescribed drugs elsewhere. If the drugs are too expensive, I will not bother buying them. — 25-year-old migrant from Togo

The influence of cultural, religious, and personal beliefs on healthcare decisions among migrant women is a critical aspect that shapes their health-seeking behaviors and treatment preferences. The study participants highlighted the significant role of cultural practices and familiarity in guiding their healthcare choices, with some individuals expressing a preference for herbal remedies based on traditional knowledge and experiences within their communities. The following participant shared her positive experience with herbal remedies, emphasizing how these traditional treatments have been effective for her and her family:

It's more of a cultural tradition passed down through generations. Herbs worked for my mom, and they work for me too. My body has adjusted to them very well, so I usually don't consider going to the health center. I trust these remedies because they have been a part of my family's health practices for as long as I can remember. They are not only familiar but also accessible and affordable, which makes them a preferred choice for me and many others in my community. — 26-year-old migrant from Niger

However, a key informant attributed the preference for herbal remedies to ignorance and a lack of education among migrant women. She emphasized that traditional practices and advice from older, uneducated women often dominate healthcare decision-making processes. This reliance on informal knowledge suggests a significant gap in health literacy and access to evidence-based information among certain segments of the migrant population. The participant noted that many migrant women trust the guidance of elderly women in their community over formal healthcare providers, often because these elderly women have successfully managed health issues in the past using traditional methods. This deep-rooted trust in cultural practices and a lack of exposure to modern medical information contribute to the persistence of using herbal remedies, even when formal healthcare might offer more effective solutions:

The major issue is ignorance and lack of education. Many migrant women often take advice from older, uneducated women in their communities, as these elder women are perceived as knowledgeable and trustworthy. Their husbands also insist on trusting these women because they were the ones who assisted in their own births, reinforcing the belief that these elder women can be trusted to deliver their unborn children as well. This reliance on traditional knowledge over formal medical advice indicates a significant gap in health literacy and access to evidence-based healthcare information among the migrant population. This deep-seated trust in community elders and traditional practices highlights the urgent need for educational interventions and outreach programs to improve health literacy and encourage the adoption of safer, evidence-based healthcare practices. — 36-year-old Hospital Matron

Religious beliefs hold a significant influence over healthcare decisions among migrant women, as highlighted by the experiences shared by participants in the study. The intersection of faith and healthcare practices shapes individuals' perspectives on treatment modalities and influences their approach to managing health issues. In particular, the role of religious beliefs in guiding healthcare decisions is exemplified by the account of a participant, a Pastor's wife, who provided insights into her personal views on the integration of spirituality and medical treatment:

Some people avoid going to the clinic for various reasons, including religious beliefs. In certain denominations, the use of drugs is discouraged because there is a belief that only God, by His grace, heals us. However, I hold a different perspective. Even though I am a pastor's wife, I believe that God can use drugs as a medium to heal us. God doesn't need to come down to earth to heal us directly; instead, He has provided us with drugs. We must combine prayer with medical treatment, recognizing that God created both the leaves and the drugs for our benefit. — 35-year-old migrant from Benin Republic

The utilization of health care facilities among migrant women is significantly influenced by recommendations from friends and family members, especially from fellow migrants within their social networks. The reliance on referrals and testimonials from trusted individuals plays a crucial role in shaping healthcare-seeking behaviors and decisions, highlighting the importance of interpersonal relationships and community support in accessing essential health services. The following participant, a Togolese food seller and mother of two, shared her experience on the impact of recommendations on her decision to visit a health center. She highlighted that the primary reason for seeking care at the health center was for immunization, a crucial aspect of child health:

The primary reason for my visits to the health center is for immunization. Given the tender age of my children, a friend strongly recommended that I bring them here for their immunization shots, emphasizing the importance of safeguarding their health through this vital preventative measure. She explained how regular immunizations could prevent serious illnesses and protect their developing immune systems. Additionally, my friend shared personal experiences of witnessing the positive effects of immunization on her own children's health, instilling confidence in me regarding the efficacy of this healthcare practice. Her reassurances and firsthand accounts have been instrumental in my decision to prioritize immunizations, ensuring that my children receive the necessary protection to thrive in their early years. — 32-year-old migrant from Togo

Similarly, another participant from Togo recounted the support and guidance received from family members regarding healthcare decisions for her child:

Recommendations from others significantly influence my decisions. One of my sisters from Togo advised me to take my newborn baby to the health center for injections to ensure good health. Her recommendation carried weight, as she had experienced positive outcomes with her own children after receiving similar care at the facility. She shared stories of how her children thrived after receiving their immunizations, free from many common illnesses that unvaccinated children often suffer. Consequently, I didn't seek antenatal treatment at that facility, opting instead to prioritize my child's health based on trusted advice within my community. This guidance from my sister, who I deeply trust, reinforced my belief in the importance of following through with recommended health practices, underscoring the value of community support and shared knowledge in making healthcare decisions. — 28-year-old migrant from Togo

This study explored how migrant women accessed and utilized health care facilities in urban slum communities in Nigeria. Three themes were constructed from the data relating to the level of access to healthcare services and utilization of health facilities among migrant women. There were three points of discussion that are particularly relevant to these findings within the context of public health approaches to addressing healthcare access and utilization.

First, this study revealed that international migrant women living in impoverished urban slums face significant housing challenges. Majority of the women reside in makeshift and incomplete buildings, which underscores the precarious nature of their accommodation. Despite these substandard conditions, the resilience and adaptability demonstrated by the participants highlight a fundamental aspect of their experiences: the prioritization of shelter, irrespective of its quality. The lack of privacy and dignity associated with using communal or makeshift toilets can lead to feelings of shame, embarrassment, and vulnerability among women, impacting their overall well-being and sense of self-worth. This finding is consistent with research which found that migrants tend to be poorer, less likely to be employed, and may live in less stable housing compared to non-migrants (Malik et al., 2020; Omole, 2010). This study also demonstrated that access to clean water is a critical concern for migrant women. The findings from the study revealed that many migrant women rely on communal or nearby sources for water, which often entails long distances or additional costs. This reliance on external sources not only underscores the lack of basic amenities in their living conditions but also imposes an extra burden on these women. The reliance on communal or nearby water sources may raise concerns about the quality and safety of the water available to these women. Inadequate access to clean water can pose health risks, exposing individuals to waterborne diseases and contaminants that can further compromise their well-being. The study highlighted the prevalence of ailments linked to environmental factors such as stagnant water, poor waste management, and overgrown vegetation, which create ideal conditions for disease vectors like mosquitoes. Previous research has shown that access to clean water is a critical issue in many urban slums, leading to contracting communicable diseases such as diarrhea (Zwane & Kremer, 2007). Sanitation facilities pose another significant challenge for many migrant women. The study demonstrated a severe lack of proper sanitation infrastructure, exposing migrant women to various health and safety risks. Researchers have previously recognized that overcrowding and poor environmental sanitation are issues faced by women in slum settlements (Akinwale et al., 2014). The shared nature of these facilities can lead to overcrowding, long wait times, and discomfort, further exacerbating the challenges faced by migrant women.

Second, this study demonstrated that a notable trend among migrant women is the preference for traditional remedies, such as herbal treatments and consultations with traditional healers and auxiliary nurses, over seeking care at formal healthcare facilities. This inclination is deeply rooted in personal beliefs, cultural practices, and the perceived effectiveness of herbal treatments in managing health conditions. Similar research had shown that in instances of minor ailments, herbal-based remedies are favored over allopathic treatments due to their cost-effectiveness among many migrant women (Li et al., 2020). This approach aligned with her belief in holistic healing and the importance of traditional medicine. Financial constraints and a lack of awareness about the affordability of healthcare services emerged as significant barriers to accessing formal medical care among migrant women in this study. Many migrant women perceived formal healthcare as unaffordable due to financial limitations and a lack of information about the cost of services. This is consistent with the study by Chuah et al (2018) who identified health illiteracy and lack of awareness as barriers to health care access among migrants. This misconception leads them to spend money on unnecessary medications from PMVs (also known as chemists), resulting in higher overall expenses and delayed professional medical intervention. Studies have previously recognized that financial support may not be easily accessible to international migrants as they may lack access to stable sources of income (Anderloni & Vandone, 2008; Solheim et al., 2022). The study brought to light a significant trend among participants, indicating a reliance on self-care practices for addressing their health needs, through the purchase of medications from PMVs or chemists. This preference for self-care methods underscores a practical approach to managing minor ailments and health concerns among the participants themselves. However, a distinct pattern emerges when it comes to the healthcare decisions regarding their children, revealing a clear preference for seeking professional medical care at health centers. Truly, PMVs frequently serve as the initial point of contact within many urban slums, with a greater proportion of visits to these PMVs attributed to new conditions rather than pre-existing ones (Onuegbu et al., 2023; Onwujekwe et al., 2022). The participants' inclination towards self-care for themselves may stem from factors such as religion, convenience, familiarity with traditional remedies, or cost considerations associated with over-the-counter medications obtained from PMVs or chemists. In contrast, the prioritization of professional medical care for their children suggests a heightened level of concern and a proactive stance towards safeguarding their children's well-being.

A final point for discussion arising from this research relates to factors that influence accessibility and utilization of healthcare facilities among migrant women. Migrant women residing in urban slums demonstrate a range of perceptions towards healthcare personnel, reflecting a spectrum of experiences encompassing both positive and negative encounters within the healthcare system. Some expressed contentment with the treatment provided by healthcare personnel, interpreting occasional scolding from healthcare providers as a demonstration of care and affection, indicating a high level of tolerance and a profound need for support despite encountering what may be perceived as harsh interactions. Others suggested that the quality of treatment received often relied on personal relationships with healthcare providers or financial incentives, indicating potential biases or informal practices that could influence the care provided to migrant women. The identification of a spectrum of perceptions towards healthcare personnel among migrant women extends previous research by highlighting the complexity of dynamics that influence individuals' interactions with healthcare providers (Braithwaite et al., 2017; Khan et al., 2018). This underscores the need for a nuanced understanding of healthcare experiences to address the diverse needs and preferences of migrant populations effectively. The recognition of potential influence of informal practices within the healthcare system on treatment quality expands on existing literature that discusses systemic issues affecting healthcare delivery to migrant populations (Acquadro-Pacera et al., 2024). This emphasizes the importance of addressing structural factors and promoting transparency in service provision to enhance the overall healthcare experiences of migrant women. Distance to healthcare facilities plays a pivotal role in shaping healthcare utilization patterns among migrant women, as evidenced by the experiences shared by participants in the study. As a result, many migrant women opt for more accessible herbal remedies instead of seeking care at a health center. This finding aligns with previous studies that highlights geographical barriers as significant determinants of access to healthcare services (Lankila et al., 2016; Okwaraji et al., 2015). Financial constraints represent a significant barrier to accessing healthcare services for the women. The inability to afford necessary medications and healthcare services due to financial limitations poses a considerable challenge. This economic barrier often acts as a deterrent to purchasing prescribed medications, potentially compromising health outcomes. As the study showed, this is yet another reason the women turned to midwives or traditional herbs for remedies. Truly, past studies have identified economic factors as key determinants of healthcare access for vulnerable populations, including migrants (Jayeweera, 2021; Lebano et al., 2020). Cultural and religious beliefs significantly shape healthcare decisions among migrant women. Some participants expressed a strong preference for herbal remedies based on traditional knowledge and community experiences. This perspective illustrates the nuanced interplay between faith and healthcare practices among migrant women. Similarly, previous studies have emphasized the impact of cultural beliefs on healthcare decisions among migrant populations (Levin-Zamir et al., 2017). The utilization of healthcare facilities among migrant women is significantly influenced by recommendations from friends and family members within their social networks. The reliance on referrals highlights the importance of interpersonal relationships and community support in accessing health services and demonstrates the critical role of social networks in shaping healthcare-seeking behaviors and decisions. This aligns with various studies that point that social networks exists as an effective way to influencing health seeking behavior of migrants (Kim et al., 2015; Ryan, 2011). Social networks serve as channels for information dissemination and guidance on healthcare services. Recommendations from peers and family members can provide valuable insights into available healthcare options, quality of services, and the overall patient experience, influencing individuals' decisions to seek care

Limitations

There are three limitations associated with this study. First, language barrier posed a significant challenge, as most participants were not proficient in English. To facilitate communication, researchers conducted interviews in Pidgin, an English-based creole language widely spoken across Nigeria. However, even Pidgin was not universally understood by all participants. For those unable to communicate in Pidgin, interviews were conducted in Yoruba, the predominant local language in the study area. This language barrier primarily arose because the participants originated from French-speaking countries, necessitating their learning of Pidgin English or Yoruba to communicate more effectively upon arriving in Nigeria. The need to use multiple languages for effective communication underscores the importance of linguistic adaptability in research involving diverse migrant populations and highlights the challenges faced by migrants in adapting to new linguistic environments.

Second, many participants were initially reluctant to engage in the study, fearing that the researchers might be government officials. This apprehension stemmed from concerns about their immigration status, as many were either undocumented or had unresolved legal issues related to their residency in the country. This mistrust posed a significant barrier to data collection, as it limited the openness and willingness of participants to share their experiences and challenges. Overcoming this barrier required building trust and ensuring participants of the confidentiality and non-governmental nature of the research. Addressing these concerns is crucial in future studies to facilitate more comprehensive and candid participation, thereby yielding richer and more accurate data on the healthcare experiences of migrant women.

Third, this study was limited to a single location in Lagos due to funding constraints. Conducting research in additional locations across Nigeria, where there are also significant populations of migrant women, would have provided a more comprehensive understanding of their healthcare experiences and challenges. Expanding the study to include diverse regions would have captured a wider range of cultural, social, and economic factors influencing healthcare access and utilization among migrant women in Nigeria. This broader scope would have enriched the data and potentially revealed regional variations and commonalities in healthcare needs and barriers faced by migrant women throughout the country.

This study highlighted the complex interplay of factors influencing the access to and utilization of healthcare facilities among migrant women in urban slum communities in Nigeria. Housing instability, lack of access to clean water and sanitation facilities, cultural beliefs, financial constraints, and social networks all play crucial roles in shaping healthcare-seeking behaviors among this vulnerable population. The findings underscore the urgent need for targeted public health interventions to address the structural determinants of healthcare access and utilization among migrant women. Improving housing conditions, providing access to clean water and sanitation infrastructure, and addressing economic barriers to healthcare access are paramount. Culturally sensitive healthcare programs that respect traditional healing practices while promoting evidence-based medical care can help bridge the gap between migrant women's healthcare needs and available services. Furthermore, community-based interventions that leverage social networks and peer support systems can enhance health literacy and facilitate access to healthcare services. By empowering migrant women to make informed healthcare decisions and providing them with the necessary resources and support, we can work towards achieving health equity and improving the overall well-being of migrant populations in urban slum communities. The implications for public health are clear: Addressing the multifaceted challenges faced by migrant women requires a comprehensive and holistic approach that takes into account their unique social, cultural, and economic contexts. By addressing these barriers and promoting equitable access to healthcare, we can strive towards achieving the goal of health for all, regardless of socioeconomic status or migration status.

Statement of Ethics Approval

The Ethics Committee of the University of Ibadan/University College Hospital Research Ethics Committee (UI/EC/17/0396) provided ethical approval for this study. Adherence to ethical considerations, including confidentiality, anonymity, and autonomy, was observed throughout the study. Due respect was accorded to participants who opted to withdraw from the research. Prior to their involvement, the authors explained the study to potential participants, answering any questions they had. Each participant then signed a consent form indicating their willingness to participate. This written consent process ensured that participants fully understood their involvement in the study and that their participation was entirely voluntary.

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The authors declare no competing interests.

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Beyond Borders: Exploring the Lived Experiences of International Migrant Women in Nigeria, a Deep Dive into Healthcare Realities and Utilization

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Abstract

Introduction

Methods

Results

Living Conditions of International Migrant Women

Pattern of Healthcare Utilization

Factors Influencing Accessibility and Utilization of Health Care Facilities

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

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