Investigating and Improving Access to Reproductive Healthcare for Vulnerable Migrant Women in France

Investigating and Improving Access to Reproductive Healthcare for Vulnerable Migrant Women in France: A Survey Protocol for a Mixed-Method Interventional Cohort Study Lorraine Poncet1,2, Armelle Andro3, Mireille Eberhard4, Marion Fleury5, Maud Gelly6, Danielle Hassoun, Veronica Noseda7, Françoise Riou5, Claire Scodellaro3, Alfred Spira2 1 Université Paris Sud Inserm CESP U1018, France 3 Institute of Demography, Université Paris 1 Pantheon Sorbonne, France 4 URMIS, Université Paris 7, France 5 Observatoire du Samusocial de Paris, France 6 CRESSPA, Université Paris 8 Vincennes, France 7 Plateforme ELSA, c/o Sidaction, France 2 ABSTRACT Background: Homelessness and housing instability in the host countries are central features of the experience of migration to the EU. Although migrant women across the EU encounter obstacles in accessing healthcare services, little is known on the health and access to healthcare services for unstably housed migrant women. The DSAFHIR project aims to better describe the risks faced by migrant women in situations of administrative and social vulnerability, to analyze the barriers to access healthcare and to test specific health interventions. Methods: The DSAFHIR project consists of a two-wave mixed-method survey and the implementation of two tailored sexual health interventions. 474 migrant women aged 18 to 77 years housed in social hotels were surveyed at inclusion. After the implementation of sexual health interventions, respondents were contacted for the follow-up survey (n=284). Discussion: The project provides needed data on migrant women’s health and healthcare access, including non-French speakers. It allows to draw lessons on feasibility and acceptability of quantitative and qualitative surveys on this hard-to-reach population. A high response rate in both waves of the survey (84% and 85%) suggests good acceptability. The attrition is comparable to other migrant longitudinal surveys (60% of the original sample completed the follow-up survey, or 40% of attrition), suggesting that relying on cell phones is possible for follow-up even in contexts of housing instability. Funding and ethics: This study is supported by a grant from the French National Research Agency (ANR) and received ethics approval from the People Protection Committee for medical research (CPP West 6). ISRCTN registration number: ISRCTN13610775. Retrospectively registered 17 June 2019. Social Science Protocols, December 2019, 1-13. http://dx.doi.org/10.7565/ssp.2019.2672 1 1. Background 1.1 Rationale In 2016, 2.4 million people migrated to a European Union (EU) member state from outside the EU and 1.8 million migrated from another EU member state (Eurostat, 2016). The number of migrants to Europe has increased in recent years due to poverty, instability and the conflicts in the Middle East, Africa, Eastern Europe and other regions of the world. In 2016, 1,206,120 people applied for asylum in an EU member state. This number has more than doubled compared to 2014, when 563,345 people applied for asylum in the EU. In 2017, the number dropped to 649,855 people (Eurostat, 2018). Of the 4.2 million migrants, 45% were women (Eurostat, 2016). While work migration to Europe has traditionally mostly consisted of men able to work - young and healthy, as theorized by the healthy migrants effect (Wallace & Kulu, 2014) -, refuge and forced migration involves women and families: couples, women migrating alone, women migrating with children, pregnant women, unaccompanied minors and older people. Migrant women are likely to experience long, dangerous, sometimes violent and traumatic migration journeys, and to encounter challenging conditions in host countries. Reports across several EU nations concur that their specific needs should be addressed (Freedman, 2017; Médecins du Monde, 2016; UNHCR, 2016). Difficulties for migrants to access healthcare services in EU countries have been documented: difficulties with reading or speaking the language, lack of familiarity with the healthcare systems in host countries, residential instability, and lack of documentation and healthcare coverage (Chauvin, Parizot, & Simonnot, 2009; Keygnaert et al., 2014; Woodward, Howard, & Wolffers, 2014). The situation is especially dire for sexual and reproductive healthcare services for migrant women (Council of Europe Commissioner for Human Rights, 2017; Keygnaert et al., 2014, 2016). The highest share of female immigrants was reported in France (51%) (Eurostat, 2016) where 378,000 people migrated from another country in 2016, and only 106,282 residence permits were granted. Among all migrants in France, only asylum seekers benefit from a dedicated housing system, which housed only 50 to 60% of them in 2017. In 2016, 19,595 people were granted asylum, representing only 25.3% of asylum applications (Office Français de l’Immigration et de l’Intégration, n.d.). Facing this gap, homeless migrants, half of them women, with various administrative status, have turned to the generic public housing system for homeless individuals and families that provides housing in emergency housing centers and, because of capacity shortage, subsidized low-end hotels. Thousands of families are housed every night in hotels scattered across the Paris metropolitan region (Guyavarch & Le Méner, 2014; Le Méner & Oppenchaim, 2012; Yaouancq et al., 2013), which they access through the “Samusocial de Paris”. Living conditions in these hotels are detrimental to health (Vandentorren et al., 2016), notably in terms of nutrition and mental health. As hotels are often in remote areas without regular public transportation, accessing commodities and service providers is challenging. Interventions tailored to improve immigrants’ health have been relatively scarce in European countries compared to the United States (Diaz et al., 2017). Many interventions focused on specific immigrant groups (Andersen, Høstmark, & Anderssen, 2012; Lee-Lin, Menon, Leo, & Pedhiwala, 2013) and many suffer from hospital setting biases (Thompson et al., 2012; Villadsen, Mortensen, & Andersen, 2016; Wang, Lin, Yang, Tsai, & Huang, 2012): recruiting participants in a hospital leaves out the people that are furthest from care and could benefit most from the intervention. Social Science Protocols, December 2019, 1-13. http://dx.doi.org/10.7565/ssp.2019.2672 2 1.2 Objectives Our objective is to present here the methodology used in the DSAFHIR research project (Rights and Health of isolated migrant women housed in hotels). We aim to highlight the rationale and the design of study and discuss the obstacles and successes encountered. We hope to contribute to the discussion and knowledge concerning research and data collection in a hard-to-reach, culturally diverse, vulnerable and mobile population. The DSAFHIR project analyzed the production of social and gender inequalities in terms of sexual and reproductive health risks and social protections in asylum and refugee s (...truncated)