The last decade has been defined by the forced displacement of an unprecedented number of people, on a scale not seen since World War II. As of 2018, more than 71 million people across the globe have been forced to migrate as a result of conflict, natural disasters, drought and famine. More than 19 million crossed international borders seeking safety, and were formally registered as refugees. Forced migration has placed stress and pressure on surrounding low-and middle-income countries. This has been most notable in the Middle East and North Africa as a result of the crisis in Syria. Host countries in the Middle East and North Africa are overwhelmed by this rapid influx, particularly by the healthcare needs of this population. Stakeholders face difficulties providing health services to refugees, owing to the increased number of refugees in urban settings, the large demands on host country health systems and the epidemiologic transition towards non-communicable diseases (NCDs). Health challenges have been exacerbated by weaknesses in the global humanitarian architecture, that result in a fragmented and competitive sector that is unprepared for the current context. Few comparative analyses have examined the diversity of policies and practices aimed at improving services for urban-based refugees with NCDs in the MENA region. Furthermore, a variety of quantitative studies examined NCD incidence, prevalence and service utilization. However, these studies have quickly become outdated and do not explore, in adequate depth, the refugee experience and perspective on accessing NCD services in urban settings. Lastly, numerous NCD interventions have been recommended for LMICs. However, very little guidance exists to support actors addressing these health concerns in crisis-affected contexts. As a result, this dissertation is presented in three papers and responds to these gaps in the literature. Each paper focuses on a specific aim and research question and together they identify and provide recommendations for improvement to service delivery and policy formulation. Paper 1 identifies policies and practices, implemented by host countries and humanitarian actors, aimed at improving access to NCD services for urban refugees in the Middle East and North Africa. Paper 2 examines, using qualitative methods, the healthcare access experience of urban-based Syrian refugees who have been diagnosed with NCDs in Jordan. The third portion of this dissertation (Paper 3) is a policy series that provides recommendations for the government of Jordan and humanitarian actors to improve healthcare access for urban-based refugees with NCDs. It is anticipated that this series of publications will be relevant to traditional and non-traditional actors that respond to the health needs of refugees in urban settings in the MENA region.

This thesis explored the health practices and religious beliefs of the recent Soviet Pentecostal refugee population in the Portland, Oregon metro area. The methodology consisted of 25 in-depth interviews over a period of twelve months. Soviet Pentecostal refugees' health practices are influenced by their religious belief system which is Pentecostalism. The four primary factors that were found to have an affect on the refugees' health were lifestyle practices; coherence; or the meaning of suffering that religion provides; cohesiveness, or group belonging to the religious community, and world view provided by the underlying theology. The language barrier, distrust of outsiders, unfamiliarity with their belief system, and a limited understanding of their experiences of persecution may limit effective health care by professionals.

Refugee women face several health and well-being risks in conflict settings. Intimate partner violence (IPV), military violence, poor sexual and reproductive health (SRH), early marriage, and unemployment are some of the competing challenges that refugee women face globally. IPV has been associated with mental health problems,1–3 unwanted pregnancy, pregnancy complications, STIs, and unsafe abortion practices,4 HIV,5–8 long term disabilities, chronic pain, and increased mortality and morbidity in refugee settings.9–12 Likewise, low, inconsistent, and ineffective use of modern spacing methods (MSM) of contraceptive has been linked to unplanned pregnancies, risk of abortions and unsafe abortions, maternal, infant and child morbidity and mortality, human immunodeficiency viruses (HIV), sexually transmitted infections (STIs), and obstetric complications as well as high fertility and poverty. Similarly, low economic engagement and/or unemployment of refugee women has proven to cause significant social, economic and health cost.13 Refugee women’s health and well-being are associated with individual, interpersonal, and societal level factors such as their age, education, social norms around fertility, household size, and age at marriage, contraceptive use, decision-making agency, socio-economic conditions, access to and affordability of health services and care, and acculturation in host countries among other factors. This dissertation examines how some of these multi-level factors influence women’s IPV experiences, contraceptive use, and economic engagement in income-generating activities. The first dissertation paper examines the prevalence of lifetime IPV among a sample of 191 health-care seeking women refugees and asylum seekers in Malaysia. Using Bronfenbrenner’s socio-ecological framework and integrated theory of gender and power, I examine multilevel factors associated with lifetime IPV. I also examine the relationship between contraceptive use and lifetime IPV. About one-third (28.30 %) of refugee women reported having experienced lifetime IPV. My hypotheses were partially supported in this study. There were significant associations between marital status, household size, contraceptive use, and food insecurity and lifetime IPV experiences in the bivariate analysis. Age, education, gender-based violence, time spent in Malaysia, and clinic were women were recruited from were not significant in the bivariate analysis. There were no associations between socio-demographic variables like age, education, household size, time spent in Malaysia and the clinic in the unadjusted as well as adjusted models. However, there were significant relationships found between marital status, contraceptive use, and food insecurity and lifetime IPV experiences in the adjusted model. Widowed, separated, and divorced refugee women were significantly more likely to report lifetime IPV experiences relative to women who reported themselves as married at time of survey [OR: 2.56, 95% CI: 1.09, 6.03] compared to women did not report lifetime IPV experience in the adjusted multivariable logistic model, rejecting my hypothesis. Also, in line with my hypothesis, women who reported using permanent methods of contraceptives were significantly more likely to report lifetime IPV experiences than no contraceptive use [0R: 8.70, 95% CI: 1.95, 38.64] compared to women who did not report lifetime IPV experiences in the adjusted multivariable logistic model. In line with my hypothesis, women who reported themselves as being food insecure were more likely to report lifetime IPV experiences than no food insecurity [OR: 0.40, 95% CI: 0.18, 0.89] compared to women who did not report lifetime IPV experiences in the adjusted multivariable logistic model. The second dissertation paper examines the prevalence of types of MSM of contraceptive use (female controlled MSM of contraceptives such as intrauterine devices (IUDs), implants, injectables, oral contraceptives (OC); male involved MSM of contraceptives such as condoms; and no contraceptives) among a sample of 307 married Syrian refugee women in Jordan. Using Bronfenbrenner’s socio-ecological framework and integrated theory of gender and power, I examine multilevel factors associated with MSM of contraceptive use. I also examine the relationship between early marriage and contraceptive use and the relationship between past-year IPV and contraceptive use. About two-fifth (38.44%) of women reported using female controlled MSM (IUDs, injectables, pills, and implants), a little more than one-tenth (11.73%) reported using male involved contraceptives (male condoms), and half of them (49.84%) reported using no contraceptives (includes natural methods and no forms of contraceptive methods). My hypotheses were partially supported in this study. Socio-demographic variables such as age, head of household, and reproductive health care services received in the past six months were significant in the bivariate association between socio-demographic variables and types of MSM of contraceptive use. And early marriage, education, children under the age of five, past-year IPV experience, Syrian governorate, and time in Jordan (acculturation) were not significant in the bivariate analysis. Women who were married prior to the age of 18 years were significantly more likely to report female controlled MSM of contraceptive use than no MSM of contraceptive use at time of survey [RRR: 1.83, 95% CI: 1.07, 3.13] compared to women who were married past 18 years of age in the adjusted multinomial logistic model. Women with children under the age of five were less likely to report male involved MSM of contraceptive use than no MSM of contraceptive use [RRR: 0.32, 95% CI: 0.12, 0.84] compared to women with children older than five years of age in the adjusted multinomial logistic model. Women who reported reproductive health care services received in the past six months were significantly more likely to report female controlled MSM of contraceptive use than no MSM of contraceptive use [RRR: 2.21, 95% CI: 1.98, 3.80] compared to women who reported not receiving reproductive health care services in the past six months in the adjusted multinomial logistic model. Contrary to my hypothesis, women who reported themselves as head of household were less likely to report female controlled MSM of contraceptive use than no MSM of contraceptive use [RRR: 0.40, 95% CI: 0.18, 0.89] compared to women who reported their husbands or family members as head of households in the adjusted multinomial logistic model. No associations between socio-demographic variables like age, education, past-year IPV, Syrian governorate, time spent in Jordan and MSM of contraceptive use in the adjusted multinomial logistic regression model were found. The third dissertation paper examines the prevalence of husbands’ no opposition to wives’ economic activity among a sample of 344 married Syrian refugee women living in non-camp settings in Jordan. Using Bronfenbrenner’s socio-ecological framework and integrated theory of gender and power, I examine multilevel factors associated with husbands’ no opposition to wives’ economic activity. I also examine the association between no lifetime IPV and husbands’ no opposition to wives’ economic activity and the association between head of the households and husbands’ no opposition to wives’ economic activity. I further examine if the relationship between no lifetime IPV and husbands’ no opposition to wives’ economic activity is moderated by women’s agency measured by if they reported themselves as head of the household. About one-third (65.12 %) of women reported husbands’ no opposition to wives’ economic activity. My hypothesis was partially supported in bivariate and multivariable logistical regression analysis. Age, education, previous work experience, head of the household, no lifetime IPV, and time in Jordan were significant in the bivariate analysis between multi-level/socio-demographic variables and husbands’ no opposition to wives’ economic activity. Of the less than half (44.77%) of women who did not experience lifetime IPV, more than one-third (70.8 %) of women reported husbands’ no opposition to wives’ economic activity relative to those who reported lifetime IPV experience (70.78 % versus 29.22 %; P=0.05). Of the more than one-fifth (22.97 %) of women who reported themselves as head of household, more than four-fifth (83.54 %) of women reported husbands’ no opposition to wives’ economic activity relative to those who did not report themselves as head of the households (83.54 % versus 16.46 %; P=0.000). In line with my hypothesis, in unadjusted (OR=1.58 95% confidence interval, CI=1.00-2.48) and adjusted (aOR=1.60, 95% CI=0.98-2.563) models, not experiencing lifetime IPV were associated with increased odds of husbands’ no opposition to wives’ economic activity. Similarly, in both the unadjusted (OR=3.44 95% confidence interval, CI=1.80-6.54) and adjusted (aOR=2.65, 95% CI=1.33-5.29) models, women who reported themselves as head of the households were associated with increased odds of husbands’ no opposition to wives’ economic activity, supporting my hypothesis. Likewise, in both the unadjusted (OR=7.97 95% confidence interval, CI=2.40-26.40) and adjusted (aOR=5.82, 95% CI=1.66-20.40) models, women who reported no IPV experiences as well as who reported themselves as head of the households were associated with increased odds of husbands’ no opposition to wives’ economic activity relative to women who reported lifetime IPV experiences and who did not report themselves as the head of the households, supporting my hypothesis. Age and education were also significant in the adjusted model. These findings affirm that IPV, contraceptive use, and women’s economic engagement are serious health and well-being issues. Results fill in the literature gaps on multilevel factors associated with IPV, contraceptive use, and women’s economic engagement. The first study contributes to the literature on how contraceptive behavior, refugee women’s marital status, and food insecurity, measured as a proxy of poverty influences refugee women’s IPV experiences. The second study contributes to the literature on how marrying at an early age, having children in the households, and receiving reproductive health services influences refugee women’s contraceptive behavior. Third paper contributes to the literature on how refugee women’s lack of IPV experiences and their improved agency/household decision making power influences their economic engagement in the host country. These findings have potential to inform health, sexual and reproductive health, social norms, and economic empowerment interventions. The implications of these findings for social policy, practice, and future research for each paper are discussed in relevant sections as well as in the conclusion section.

Refugees are not a new phenomenon and their plight has been felt the world over. Africa continues to see large numbers of people displaced through armed conflict, producing more refugees on the worlds&rsquo / most poverty stricken continent than any other.<br /> The implications of these displacements of people dislocated from their places of habitual residence create much concern, particularly in the wake of the HIV/AIDS pandemic. Such dislocations and displacements imply separation from family and communities, including socio-economic benefits that accrue to them. There is an apparent problem of accessing health services, educational services, sources of livelihood and protection from sexual and emotional abuse. Refugee children and women are said to be the most vulnerable, although until recently adolescents in armed conflict were not considered as a<br /> special group of children requiring special attention. The main objective of this research was to investigate levels of risk for HIV among refugee adolescents in Zambia and to determine how location relates to risk. Of particular interest was the difference in risk experienced in rural and urban areas. The researcher&rsquo / s hypothesis was that refugee adolescents in rural camps of Zambia are at greater risk because they lack adequate sources of income, health, and education in comparison to urban areas. The research was located within two theoretical underpinnings namely the social cognitive theory and the AIDS Risk Reduction Model (ARRM). The theory posits that a reciprocal relationship exists between environmental contexts, personal factors and behavior. The model explains how people change behavior that reduces risk for HIV by changing perceptions on sexual activity and when they enact the knowledge obtained from HIV preventive programmes. The methodology was located within both the qualitative and quantitative research<br /> approaches. Qualitative because firstly, the research is a comparative case study and secondly, it is the first time such a study is being conducted. The researcher also made use of the quantitative through the survey and secondary HIV/AIDS statistical data.

Refugees are not a new phenomenon and their plight has been felt the world over. Africa continues to see large numbers of people displaced through armed conflict, producing more refugees on the worlds&rsquo / most poverty stricken continent than any other.<br /> The implications of these displacements of people dislocated from their places of habitual residence create much concern, particularly in the wake of the HIV/AIDS pandemic. Such dislocations and displacements imply separation from family and communities, including socio-economic benefits that accrue to them. There is an apparent problem of accessing health services, educational services, sources of livelihood and protection from sexual and emotional abuse. Refugee children and women are said to be the most vulnerable, although until recently adolescents in armed conflict were not considered as a<br /> special group of children requiring special attention. The main objective of this research was to investigate levels of risk for HIV among refugee adolescents in Zambia and to determine how location relates to risk. Of particular interest was the difference in risk experienced in rural and urban areas. The researcher&rsquo / s hypothesis was that refugee adolescents in rural camps of Zambia are at greater risk because they lack adequate sources of income, health, and education in comparison to urban areas. The research was located within two theoretical underpinnings namely the social cognitive theory and the AIDS Risk Reduction Model (ARRM). The theory posits that a reciprocal relationship exists between environmental contexts, personal factors and behavior. The model explains how people change behavior that reduces risk for HIV by changing perceptions on sexual activity and when they enact the knowledge obtained from HIV preventive programmes. The methodology was located within both the qualitative and quantitative research<br /> approaches. Qualitative because firstly, the research is a comparative case study and secondly, it is the first time such a study is being conducted. The researcher also made use of the quantitative through the survey and secondary HIV/AIDS statistical data.

<p>This study investigated the societal perception of refugee men as being a risk group, being polluted and the consequent risk of HIV infection they might face. It also determined the factors that could expose them to the risk of HIV infection while living in exile in South Africa.</p>

A Research Report submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements of the Degree of Master of Arts, Applied Ethics for Professionals. Johannesburg, 2017 / Many asylum seekers and refugees in South Africa reportedly find it difficult to access basic health care services. The issue about foreign nationals in relation to health care can be considered from different angles. The concept of access, though, points to gate-keeping. Gate-keeping is the practice that guides decision making about who has access to what and to what extent they might enjoy benefits. In this essay, the question of whether gate-keeping is a morally justifiable practice in South Africa in relation to asylum seekers and refugees’ right to basic health care services is explored. It is concluded that carefully considered and consistently implemented gate-keeping might be a morally justifiable practice that could contribute to ensuring that resources are distributed fairly. It is also argued that the kind of gate-keeping often observed is inconsistent with human rights and Ubuntu precepts. These moral frameworks seem to be the main ones shaping the view of most South Africans as well as our institutional arrangements. Considering the current South African context in which asylum seekers and refugees have difficulty in accessing basic health care services, patriotic bias claims are considered. However, it is concluded that partiality towards compatriots ought not to hold sway when any human being’s basic needs are at stake. / MT2018

<p>This study investigated the societal perception of refugee men as being a risk group, being polluted and the consequent risk of HIV infection they might face. It also determined the factors that could expose them to the risk of HIV infection while living in exile in South Africa.</p>

The purpose of the study is to investigate lived experiences of refugees when accessing healthcare services in Pretoria, South Africa. A qualitative phenomenological research approach was followed which assisted in exploring and describing the day-to-day lives of refugees living in Pretoria regarding their health outcomes. Face-to-face interviews were conducted on purposively selected participants, representing refugees from different African countries ranging from age 27 to 58 years. Collected data were transcribed, coded, and relevant themes were extracted and analysed by employing Colaizzi's seven-step analysis framework. Main findings demonstrated that the public healthcare services accessed by refugees, compared to private healthcare services, can be described as mostly dysfunctional. Also, healthcare providers from public healthcare services are often hostile towards refugees of African descent. Failure to speak a local language, unofficial documentation as viewed by a healthcare provider on duty, being a foreigner, and failure to pay undue consultation fees led to refugees being denied access to healthcare or receiving negative treatment in the public healthcare sector. Recommendations for programmes to promote human rights and refugee awareness in healthcare facilities could subsequently contribute to alleviating complications around access to healthcare services, which would denote improved health outcomes for the refugees. / Health Studies / M. P. H. (Health Studies)

Thesis (Mphil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Political instability involving civil wars which had been prevailing mostly within the African Great Lakes Region caused great numbers since the 1990s of civilian populations to move to and fro within the borders and sometimes beyond its frontiers in search of both safer homes and better living conditions. Socio-economic hardships experienced by these people constrained them to engage in various migration movements, thus making them more vulnerable to a variety of diseases and pandemics, among which Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Sub–Saharan Africa has been bearing the brunt of HIV pandemic, and South Africa is believed to have the highest HIV prevalence. The present study was a quantitative survey exploring personal perception of HIV infection risk among African émigré communities of the Cape Metropolitan area. Only thirty four heterosexual active participants, who had joined their partners in South Africa after a certain period of temporary separation, were considered for final analysis using descriptive statistics. A relatively high perception of HIV infection risk was found among both males and females. However, the perceived risk did not necessarily determine sexual behaviour. No significant reciprocal relationship was found between the perceived risk and one important sexual risk behaviour. HIV and AIDS related stigma was found to be relatively high and the use of condoms prejudiced by tendencies of personal moralistic values. The present study has made relevant recommendations as to promote more preventive behaviours among the present African émigré community. / AFRIKAANSE OPSOMMING: Politieke onstabiliteit wat burgeroorloë meebring kom sedert die 1990’s meestal in die Groot Mere-streek van Afrika voor en het veroorsaak dat groot groepe van burgerlike bevolkings heen en weer tussen grense beweeg en soms grense oorsteek op soek na beter en veiliger tuistes en beter lewensomstandighede. Die sosio-ekonomiese ontberings wat deur hierdie mense ervaar is het hulle verplig om by verskeie migrasiebewegings betrokke te raak. Dit het hulle kwesbaar gemaak vir ’n verskeidenheid siektes en pandemies, waaronder die menslike immuniteitsgebreksvirus (MIV) en verworwe immuniteitsgebreksindroom (Vigs). Sub-Sahara-Afrika het die ergste van die MIV-pandemie getrotseer en Suid-Afrika het na bewering die hoogste MIV-voorkoms. Hierdie studie is ’n kwantatiewe opname wat die persoonlike persepsie van die risiko van MIV-infeksie onder Afrika-uitgeweke gemeenskappe in die Kaapse Metropoolgebied ondersoek het. Slegs 34 heteroseksuele, seksueel aktiewe deelnemers wat na ’n tydperk van tydelike skeiding by hul (lewens) maats in Suid-Afrika aangesluit het, is vir die finale analise oorweeg met behulp van beskrywende statistiek. Onder mans sowel as vroue is ’n relatief hoë persepsie van infeksierisiko gevind. Die waargenome risiko het egter nie noodwendig seksuele gedrag bepaal nie. Geen beduidende omgekeerde verhouding is tussen die waargenome risiko en een belangrike seksuele risikogedragsaspek gevind nie. Daar is bevind dat MIV en Vigsverwante stigma relatief hoog is en dat daar weens tendense van persoonlike moralistiese waardes vooroordeel teen die gebruik van kondome bestaan. Hierdie studie het relevante aanbevelings gedoen om meer voorkomende gedragspatrone onder die huidige Afrika-uitgeweke gemeenskap te bevorder.