Recent years have seen increased attention being paid to the global governance of cross-border migration – the movement of people across international borders, including asylum seekers, refugees, migrant workers and undocumented migrants (1,2). Driven in many cases by high-income countries (HICs) who want to restrict the inward movement of people from low- and middle-income countries (LMICs), these discussions tend to focus on concerns around the role of the nation state and sovereignty, and push for the securitisation of cross-border migration through both border management and immigration legislation (3). These ambitions were demonstrated in the adoption of two global compacts in December 2018 – the Global Compact for Safe, Orderly and Regular Migration (GCM) and the Global Compact for Refugees (GCR) - that aim to guide responses to the governance of migration globally (4,5). Whilst a discussion of the content of these Compacts is beyond the scope of this paper, concerns have been raised about the ways in which both the GCM and GCR can be applied to support, or to undermine, the rights of people on the move - including efforts to achieve Universal Health Coverage (UHC) (6–17). Despite attempts by global health actors to push the migration and health agenda for more than a decade, attempts to achieve health for all persist as migrant populations continue to be left-behind (18,19). This is particularly so for marginalised migrant groups, including those who sell sex, undocumented migrants, and people seeking asylum on the basis of their gender identity (18,19). Leaving migrants behind has serious implications for all, negatively affecting progress on the targets set out in the Sustainable Development Goals (SDGs) and other associated global health processes (18–22).
The South African context - associated with high levels of cross-border and internal migration - makes for an ideal case study in which to explore a mobile methodology for understanding the health-related experiences of migrants in ‘real-time’. South African health systems are not migration-aware nor mobility-competent, affecting access to healthcare for international and internal migrants (23–26). Key populations, including sex workers and trans persons, who are known to be particularly mobile, face additional barriers to access as a result of their gender and/or sexuality (27). Furthermore, while more women are migrating into South Africa they face particular challenges in the informal economy in which many work (28), accessing healthcare (29) and fulfilling care roles (30).
1.1 Improving responses to migration and health in South Africa
Drawing on existing research literature, we highlight four specific challenges that are limiting the development of improved responses to migration and health globally, although our focus here is on South Africa: (1) the focus on individual migrants rather than on the process of migration; (2) the prioritisation of cross-border migrants and the exclusion of internal migrants; (3) an insufficient understanding of the relationship between gender and migration and health; and, (4) the methodological limitations for obtaining ‘real-time’ data over time and place.
Firstly, the field of migration and health tends to focus on the movement of individual migrants – including those seeking asylum – rather than on the process of migration itself (18,21). This often results in efforts that, for example, aim to make health systems ‘migrant-sensitive’ – through cultural competency training for healthcare workers – rather than ‘migration-aware’, whereby systems would address the movement of people within and between countries (23,26).
Secondly, whilst limited, efforts to address migration and health focus on the movement of cross-border migrants and overlook internal migrants – those who move within their countries of birth – and intra-regional migrants, both of which are prevalent in LMIC contexts. Whilst these movements account for a significant proportion of all global migration, they remain left-behind in global migration and health governance discussions that predominantly focus on the movement of people from LMICs to HICs (21,31,32).
Thirdly, the importance of understanding the gendered nature of migration – including what has been referred to as the feminisation of migration and the importance of moving beyond binary understandings of gender – is increasingly recognised by policy makers and researchers as critical in the development of appropriate approaches to the governance of international migration (7,33–35). Whilst it is well established that gender is a key factor for understanding health seeking behaviours and experiences (36,37), current research on migration and health exploring gender tends to focus exclusively on the experiences of migrant women, and rarely examines how this further interacts with other social identities.
Finally, within the field of migration and health research, we have not found examples of methodologies that are able to capture ‘real-time’ data about health needs, healthcare seeking experiences, and interactions with healthcare systems over both time and place. Longitudinal research on migration and health tends to make use of repeated quantitative measures collated in a single geographic location that rely on participant recall of experiences, time, and place, such as through Demographic Health Surveillance Surveys (DHSS) (38). While qualitative approaches for exploring migration and health over time largely rely on repeated face-to-face interactions between the researcher(s) and participants at different moments, or make use of mobile technology to remain in contact, conduct interviews or, increasingly, explore the potential of mobile technology for participatory research (39). However, these approaches are rarely designed to capture experiences over time and place as they are happening – something particularly important when working with migrant groups. Nor do they tend to explore the capabilities of technology as a data collection tool itself.
1.2 Exploring WhatsApp as a research tool for exploring migration, mobility, health and gender in South Africa
In order to explore intersections between migration, mobility, gender and the South African health system – and taking into consideration the four concerns raised above - the Migration, Gender and Health Systems (MiGHS) project aims to explore the use of a mobile technology as a tool for researching the health-related experiences of international and internal migrants in ‘real-time’. MiGHS is a collaboration between the Universities of the Witwatersrand (Wits) and Cape Town (UCT), the London School of Hygiene and Tropical Medicine (LSHTM) and the South African National Department of Health (NDoH). Funded by the UK MRC Wellcome Trust Health Systems Research Initiative, the project draws on previous research in the field of migration and health undertaken by the collaborators (25,40,41).
Following a review of the literature, we chose to explore the use of WhatsApp Messenger - a social media platform operated on smart phones – in our research. Four key reasons explain our decision to use WhatsApp: its prevalence as a means of communication in Southern Africa (42,43); the application’s affordability; its ease of use, including allowing the participant to respond to survey questions and share their location within WhatsApp; and – perhaps most importantly – the ability to retain contact with participants should they cross international borders (44–49).
To date, the use of WhatsApp as a tool for data collection in health research has been limited (50). Our scoping review indicates that WhatsApp has either been used to disseminate survey tools, usually through sharing a link to an online SurveyMonkey or Google Form, or, through the creation of a WhatsApp Group as an intervention to facilitate communication between healthcare workers. We found that there is little published that assesses the use of WhatsApp as a data collection tool in health research and communication interventions. Importantly, even within the literature that does exist, limited attention has been paid to the ethical implications of using WhatsApp or the ways in which existing social and economic inequities may affect its use.
1.3 A pilot study
In this paper we reflect on the results of a pilot study that sought to investigate the potential use of mobile technology to retain contact with 400 mobile study participants to be recruited in four areas of South Africa for a 12-month period to document their experiences of health systems usage in real-time. To explore the feasibility of this study, a four-month pilot project was undertaken between October 2019 and January 2020 to explore the opportunities and challenges associated with the use of WhatsApp as a research tool. This paper reflects on the successes and challenges of the pilot and how it has informed the main study. Through documenting our use of the application in this research and the ways the pilot has shaped our thinking as we move into the main project, we hope to contribute insights to existing gaps in the literature on migration and health and to the development of an emerging best practice around the use of WhatsApp in health research.