Internal migration and health in South Africa: determinants of healthcare utilisation in a young adult cohort.

BACKGROUND: In South Africa, human geographic mobility is high as people engage in both permanent and temporary relocation, predominantly from rural to urban areas. Such mobility can compromise healthcare access and utilisation. The objective of this paper is to explore healthcare utilisation and its determinants in a cohort of internal migrants and permanent residents (non-migrants) originating from the Agincourt sub-district in South Africa's rural northeast. METHODS: A 5-year cohort study of 3800 individuals aged 18 to 40 commenced in 2017. Baseline data have been collected from 1764 Agincourt residents and 1334 temporary, mostly urban-based, migrants, and are analysed using bivariate analyses, logistic and multinomial regression models, and propensity score matching analysis. RESULTS: Health service utilisation differs sharply by migrant status and sex. Among those with a chronic condition, migrants had 0.33 times the odds of non-migrants to have consulted a health service in the preceding year, and males had 0.32 times the odds of females of having used health services. Of those who utilised services, migration status was further associated with the type of healthcare utilised, with 97% of non-migrant rural residents having accessed government facilities, while large proportions of migrants (31%) utilised private health services or consulted traditional healers (25%) in migrant destinations. The multinomial logistic regression analysis indicated that, in the presence of controls, migrants had 8.12 the relative risk of non-migrants for utilising private healthcare (versus the government-services-only reference category), and 2.40 the relative risk of non-migrants for using a combination of public and private sector facilities. These findings of differential utilisation hold under statistical adjustment for relevant controls and for underlying propensity to migrate. CONCLUSIONS: Migrants and non-migrants in the study population in South Africa were found to utilise health services differently, both in overall use and in the type of healthcare consulted. The study helps improve upon the limited stock of knowledge on how migrants interface with healthcare systems in low and middle-income country settings. Findings can assist in guiding policies and programmes to be directed more effectively to the populations most in need, and to drive locally adapted approaches to universal health coverage.

Dimensions of internal migration and their relationship to blood pressure in South Africa.

Hypertension prevalence is on the rise in low- and middle-income countries (LMICs) like South Africa, and migration and its concomitant urbanization are often considered to be associated with this rise. However, relatively little is known about the relationship between blood pressure (BP) and internal migration - a highly prevalent population process in LMICs. This study employed data for a group of 194 adult men and women from an original pilot dataset drawn from the Agincourt Health and Demographic Surveillance System in north-east South Africa conducted in 2012. Migrants in the sample were identified, tracked and interviewed. The relationship between BP and migration distance and the number of months an individual spent away from his/her home village was estimated using robust OLS regression, controlling for a series of socioeconomic, health and behavioural characteristics. It was found that migrants who moved a longer distance and for longer durations had significantly higher systolic and diastolic blood pressures compared with shorter-term migrants and those who remained nearby or in their home village. These associations remained robust and statistically significant when adjusting for measures of socioeconomic conditions, as well as body mass index and the number of meals consumed per day. Migration, both in terms of distance and time away, explained significant variation in the blood pressure of migrants in this typical South African context. The findings suggest the need for further studies of the nutritional and psycho-social factors associated with geographic mobility that may be important to understand rising hypertension levels in LMICs.

Dietary patterns and their socio-demographic correlates in the context of migration and urbanisation demonstrate nutrition transitions in South Africa.

This paper investigates the demographic and socio-economic correlates of dietary patterns in South Africa, drawing on a sample of young adults experiencing internal migration and urbanisation. We use data from the 2018 baseline survey of the Migrant Health Follow-Up Study, an original longitudinal cohort study consisting of 3,087 internal migrants and rural residents aged 18-40 nested within the Agincourt Health and socio-Demographic Surveillance System in rural northeast South Africa. We employ principal components analysis to identify dietary patterns from food frequency questionnaires and ordinary least squares regression to assess whether migration and other socio-economic characteristics correlate with specific dietary patterns at baseline. We observe five distinct dietary patterns characterised by frequent consumption of processed foods, red meat, fruits and vegetables, diverse foods, and high sugar/fat foods. We find migration to be significantly associated with more frequent consumption of both processed foods and fruits and vegetables; we also find the association between migration status and dietary patterns to be heterogenous depending on migrants' destinations. This paper extends current understanding of changing dietary patterns in the context of nutrition transitions with attention to dynamic migration processes rather than static rural-urban differences.

Urban residence and elevated blood pressure among migrant women in South Africa.

This paper demonstrates that internal migration may be contributing to rising non-communicable disease risk in low- and middle-income countries in gendered and geographically differentiated ways. With 2018 baseline data from the Migrant Health Follow-Up Study, we investigate the relationship between internal migration and elevated blood pressure (BP) among 2163 rural-origin men and women in South Africa, testing for sex differences. To examine the influence of place, we test whether the migration-BP relationship differs by migrants' destination locations, controlling for household composition, social support, prior migration, and housing quality. We find that migration is associated with elevated BP only among women, and that this association is greatest for migrants living in Tembisa township. Our research underscores that gender and migration are important social determinants of noncommunicable disease risk in low-resource, rapidly-urbanizing settings.

The impact of COVID-19 on a cohort of origin residents and internal migrants from South Africa's rural northeast.

South Africa has a large temporary migrant population with people commonly moving to metropolitan areas to access employment, while maintaining links with their rural origin households. The COVID-19 pandemic has impacted patterns of movement, livelihoods and health seeking, and the effects on internal, temporary migrants are unclear. Using longitudinal data spanning 2018 to 2020, this paper employs descriptive statistics and regression analyses to assess the impacts of COVID-19 on a cohort of 2971 persons aged 18-40 at baseline, both residents and migrants, from a rural district in South Africa's northeast. In contrast with 2018-2019, in 2020 the share of rural residents initiating a migration decreased by 11 percentage points (p<0.001), while the share of temporary migrants returning to origin households increased by 5 percentage points (p<0.001). Study participants who were continuing migrants reported fewer job losses in comparison with rural-stayers, while 76% of return migrants who were employed in 2019 were no longer employed in 2020. Further, among those who did not experience food shortages in 2019, rural-stayers had 1.42 times the odds of continuing migrants of suffering shortages in 2020. In 2020 health service use in the cohort decreased overall, with return migrants having still lower odds of utilising health services. The results highlight the differential geographic and socioeconomic manifestations of the pandemic, with worsening socioeconomic circumstances observed for rural-staying (disproportionately female) and returning populations, while continuing migrants fared relatively better. It is vital that a COVID-19 response considers the potentially heterogeneous impact of the pandemic on mobile and stable populations. Policy responses may include targeting migrants at their destinations in health promotion of COVID-19 messaging, and strengthening health care and social support in origin communities in recognition that these areas receive return migrants into their catchment population.

Internal migration, urban living, and non-communicable disease risk in South Africa.

This paper offers theoretical and substantive contributions to migration-health scholarship by employing rich panel data with biomarkers to estimate the effect of migration and urban living on non-communicable disease risk in South Africa. Internal migration and urbanization continue to be pervasive demographic and socio-economic phenomena that structure daily life in low- and middle- income countries (LMICs). Yet, how these processes affect illness and disease in low-resource settings is still not well understood. Five waves (2008-2017) of South Africa's National Income Dynamics Study data and fixed-effects modeling are used to estimate the relationship between urban residence, migration, and health. Results indicate that the migration-health relationship differs by gender: urban living for men is associated with lower blood pressure. While urban residence appears to convey a health advantage when men reside in urban compared with rural places, there is no evidence of an urban health advantage among women. Migration does, however, negatively affect women's health through higher blood pressure (BP). These findings highlight the need for further interrogation of the ways in which processes and health consequences of migration and urban living are structured by gender in LMICs. Given the importance of urbanization and the prevalence of migration in LMICs, the gendered determinants of blood pressure may be key to understanding rising hypertension incidence in contexts like South Africa.