Socio-Structural Barriers, Protective Factors, and HIV Risk
Among Central-Asian Female Migrants in Moscow
Christopher Zabrocki1, Stevan Weine1,
Stephanie Chen1, Ivana
Brajkovic1, Mahbat Bahromov2,
Sana Loue3, Jonbek Jonbekov4,
Farzona
Shoakova4
1The University of Illinois at Chicago, Chicago,
Illinois, USA; 2Prisma
Research Center, Dushanbe, Tajikistan; 3Case
Western Reserve
University, Cleveland, Ohio, USA; 4Prisma
Research Center, Moscow,
Russia
Abstract
Objective: This study aimed to build formative
knowledge on
socio-structural barriers, protective factors, and HIV sexual risk
amongst Central-Asian female migrants in Moscow.
Methods: Data
collection included ethnographic interviews in Moscow with a purposive
sample of 30 unmarried female migrants, 15 from Kyrgyzstan and 15 from
Tajikistan.
Results: Study participants reported difficulties
with
acquiring documents for legal status, financial insecurity,
discrimination, sexual harassment, and lack of support. Based on
analysis of the cases, one pathway linked lack of legal documentation
and instrumental support with elevated sexual risk. Another pathways
linked traditional cultural attitudes with both no and moderate sexual
risk.
Conclusion: Future HIV prevention efforts with
Central Asian
female migrants in Moscow should be multilevel and include: increasing
HIV and prevention knowledge and skills, promoting condom use with
regular partners, identifying and supporting cultural attitudes that
protect against HIV sexual risk behaviors, facilitating legal status,
building community support, and increasing economic options.
Keywords: HIV/AIDS, Women’s Health, Central Asia, Risk
Perception
Introduction
Women account for increasing numbers of labor migrants globally and
approximately 15 to 30% of migrants to Russia.1,2
Between 2004 and
2008, approximately 800,000 migrants traveled to Moscow from
Kyrgyzstan, and another 1.5 million from Tajikistan.3
Due to the high
prevalence of HIV in Moscow and the sexual practices of male migrants,
public health experts are concerned that migrants could be a bridge for
HIV transmission to their lower HIV prevalence home countries,
including Tajikistan and Kyrgyzstan.4,5
Female migrants may be at increased risk for acquiring HIV infection in
multiple ways. Away from their home countries’ traditional cultures
that prohibit women from engaging in non-marital sexual relations,
female migrants may be more sexually active with more partners.6-9
In
Moscow female migrants face greater difficulties with legal status than
male migrants.10,11 These difficulties can
increase their vulnerability
to exploitation, reduce their access to services, and lead to higher
STI and HIV.12-14 Illegal status may confine
female migrants to
unregistered and low-wage positions.15 To
survive, women often turn to
formal sex work or to transactional sex, resulting in greater sexual
risk for HIV.16-18 Female migrants from
developing countries often have
limited HIV knowledge, may associate condoms with promiscuity, and may
avoid condom use with regular sexual partners.19-24
On the other hand, home country religion, cultural values of
abstinence, and having friends not engaged in sexual risk behavior may
be protective factors for HIV risk.25-27 Respect
for parents’ beliefs
and values and having plans for the future have been found to be
protective against pre-marital sex.28
The WHO has shifted the emphasis of preventative health care with
migrants from a focus on individual behavior to considering the social
determinants of health.29 However, HIV risk
among the growing number of
female labor migrants globally, is presently under-investigated.30
There is a need for scientific investigations of female migrants that
build knowledge on the social determinants of health and that could
help to inform the development of HIV prevention for female labor
migrants.
This ethnographic study sought to learn about Central Asian female
migrants’: 1) working and living conditions in Moscow; 2) HIV/AIDS
knowledge, attitudes and behaviors; and 3) HIV risk in relation to
socio-structural barriers and protective factors. Lastly, the study
aimed to consider implications for future programs, policies, and
research that address the social determinants of health among female
migrants.
Methods
Sampling and Recruiting
The study purposively sampled thirty female migrants currently living
in Moscow. This sampling strategy maximized diversity on three axes:
(1) age; (2) education; (3) employment in Moscow. Fifteen were from
Kyrgyzstan and fifteen were from Tajikistan. Eligibility required that
the women be: (1) unmarried; (2) 18-35 years old; (3) in Moscow for the
first time; (4) living in Moscow less than 1 year; (5) from Tajikistan
or Kyrgyzstan; (6) able to give informed consent. In Moscow, Tajik
female migrants were recruited through several Tajik diaspora
organizations and Kyrgyz female migrants through the Kyrgyz diaspora
center. After describing the study, oral informed consent was obtained,
as approved by the IRBs of the University of Illinois at Chicago, the
Tajik Ministry of Health, the Russian Academy of Arts and Sciences, and
Case Western Reserve University.
Data Collection
With each migrant we conducted a single minimally structured interview
in English with interpretation in either Tajik or Russian by bilingual
team members.31 The interviews lasted between 60
and 150 minutes and
were conducted in convenient locations for the participants, such as
apartments, parks, cafes, or the research team’s office. Participants
were paid $20. These open-ended interviews focused on the women’s: (1)
daily lives; (2) experiences with migration and life in Moscow; (3)
home country lives and family; (4) social support and network in
Moscow; (5) HIV/AIDS knowledge, attitudes, behaviors, and risk and
prevention skills; and (6) access to healthcare and HIV testing.
Demographic information was also gathered (Table 1). All interviews
were audiotaped and transcribed into English. The initial study
questions were refined through an iterative process of data collection
and preliminary data analysis that followed standardized qualitative
methods.
Table 1: Demographic Information
|
Tajik |
Kyrgyz |
Total |
Average Age |
28.6 |
24.8 |
26.7 |
Marital Status |
Single |
10 (66%) |
8 (53%) |
18 (60%) |
Widowed |
3 (20%) |
7 (47%) |
10 (33%) |
Divorced |
2 (13%) |
0 (0%) |
2 (7%) |
Children |
0 |
8 (53%) |
8 (53%) |
16 (53%) |
1 |
5 (33%) |
4 (27%) |
9 (30%) |
2 |
1 (7%) |
2 (13%) |
3 (10%) |
Pregnant |
1 (7%) |
2 (13%) |
3 (10%) |
Education |
Secondary |
8 (53%) |
6 (40%) |
14 (47%) |
Some College |
3 (20%) |
3 (20%) |
6 (20%) |
College |
4 (27%) |
5 (33%) |
9 (30%) |
Trade School |
0 (0%) |
1 (7%) |
1 (3%) |
Employment |
Seller |
6 (40%) |
1 (7%) |
7 (23%) |
Cleaner |
4 (27%) |
7 (47%) |
11 (37%) |
Sex Work |
1 (7%) |
1 (7%) |
2 (7%) |
Other |
0 (0%) |
3 (20%) |
3 (10%) |
Unemployed |
4 (27%) |
3 (20%) |
7 (23%) |
Total |
15 |
15 |
30 |
Data Analysis
The study utilized a grounded theory approach to qualitative analysis
and Atlas/ti computer software.32,33 After
establishing coder
reliability, all transcripts were coded. Key variables, categories,
processes, and theoretical claims emerged through pattern coding and
memoing.34 The findings were reviewed by the
entire team to check for
contrary evidence.
The determination of instrumental support and legal status was done by
consensus rating of the entire research team based upon both
established definitions and knowledge gained from the female migrants.
For instrumental support we used the Tilden and Weinhart definition of
the provision of tangible goods, services or aid.35
A female migrant
was considered to have instrumental support if she identified someone
who could provide her with food, money, or employment. Regarding legal
status, we learned from official sources and from the female migrants
that it was important to consider migration documents, work permits,
and registration.36 The female migrant was
considered to have legal
status only if she reported having acquired all these documents in
Moscow. Regarding HIV sexual risk behaviors, the participants were
classified into three sexual risk categories based on their reported
current behavior as migrants: no risk (not currently sexually active),
moderate risk (currently sexually active, monogamous), and elevated
risk (currently sexually active, transactional sex or sex work).
Results
Surviving in Moscow
All of the women reported that the primary reason for leaving home and
coming to Moscow was to earn money. Although some female migrants came
with education and skills, most could only find work that was far below
their skill level. One reported, “To work here within your profession
is very difficult. I am educated in economics and have worked in a bank
as a cashier in Kyrgyzstan. It is impossible to work in such jobs here”
(Kyrgyz, 23A).
Most who were employed reported being paid too little and
intermittently or not at all. One Tajik migrant reported, “For almost
one year I’ve worked in Moscow, but I haven’t seen any money from
employers. Every time I have worked; the employer throws me out”
(Tajik, 31).
Others told of not being able to find work at all due to
discrimination. “Here I went to several places and they said you should
be a citizen of Russia, and besides, we take only Slavic appearance”
(Kyrgyz, 35). Without work or money, some women had to live on the
street. One reported, “I took these clothes from the trash dump,
because I didn’t have any money. I was suffering a lot and I’m
suffering still, I have slept in the streets and in entrances, because
there are not any good jobs and no salaries” (Tajik, 31).
Many participants reported that workplace sexual harassment was
commonplace. “Some people would touch me and pinch my butt when walking
through. I worked there almost eight months” (Tajik, 19A). Some
reported employers withholding salaries unless migrants performed
sexual favors. “In some places the employer man offered me to have sex
with him, just after that he would pay me my salary, but I refused, I
didn’t want to do that” (Tajik, 31). When she refused, she became
subject to further harassment by her employer: “For two days I worked
there and everything was fine, but the other day the boss got drunk and
wanted me to have sex with him. I didn’t agree and he started to beat
me.” Another said, “He wants me to have sex with him, but I don’t want
to have such a sexual partner, therefore he always tries to hurt me and
behaves badly towards me” (Tajik, 32).
Many female migrants reported encountering deception, greed, and
selfishness amongst other female and male migrants in Moscow. One said,
“You care about others there, and here you only care about yourself.
You become an egoist, you stop caring about others” (Kyrgyz, 23A).
Another said, “Moscow makes people lie” (Kyrgyz, 26). As a consequence
they learned to think more negatively about others and themselves. “I
think that everybody is going to cheat us again” (Tajik, 31). With
little community support, female migrants rely principally on
themselves, “Nobody except yourself can help you; you are alone in this
big city” (Kyrgyz, 27).
Not Worried about HIV
Although several female migrants reported no knowledge of HIV, most
knew something about AIDS, HIV transmission, and HIV prevention. Many
stated that HIV was present in Russians and marginalized groups, such
as sex workers, partiers, and the rich, but they did not believe that
HIV/AIDS was as prevalent in persons from their home country. “I didn’t
hear that this disease was among Tajik women, but I know that it is
spread among Russian women” (Tajik, 31). Another stated, “The rich guy
that spends money for fun is definitely infected. I am dating an
ordinary simple man who is not infected” (Kyrgyz, 28). Another said, “I
think all the street girls who work in public houses or in the street
are all infected with STIs and no man should have sex with them”
(Tajik, 19A). Female migrants reported knowing that condoms could
prevent HIV transmission; one said, “The big reason is to protect from
STIs, HIV and other infections that can be transmitted sexually”
(Tajik, 26). HIV infection was regarded as a death sentence and as a
social stigma. One migrant said, “The man that is HIV+ is just a dead
man. He is just a living body. He only has the end and nothing else”
(Kyrgyz, 28).
Current HIV Sexual Risk Behaviors as Migrants
Not Currently Sexually Active (No Risk)
Eighteen (60%) female migrants reported no current sexual activity.
Some of them were dedicated to lost partners: “The passion and the love
I had with my marriage I lost, I had a good life with my husband, but I
lost him long ago… but now my son is already a big boy and I have been
without a husband for a long time and [being single] is normal for me”
(Tajik, 35). Others wanted to remain a virgin until marriage. “We are
Muslims and we are not allowed to have sex before marriage” (Tajik,
25). Still others reported no sexual desire or an inability to find a
suitable partner, “I haven’t found such a man that I could love yet”
(Tajik, 34). Some told of being uninterested in relationships, “If you
get married you have to do what your husband and his family says. I
want to live independent and communicate with my friends when I want
and where I want” (Kyrgyz, 23A). Others prioritized different goals. “I
do not want anyone at all because if you have someone; you will not
work” (Tajik, 27A). Regarding condoms, one woman said they were not for
“love partners,” and she did not plan to use them when in a
relationship, “Those girls who do sex before marriage, I’ve heard that
they use condoms. I think only ‘street girls’ can use condoms; not
normal girls. When you love your man, why should you use it?” (Tajik,
19B). Based upon their reported current sexual behavior, as migrants
these women were not considered to be at HIV risk.
Currently Sexually Active, Monogamous (Moderate Risk)
Eight (27%) female migrants reported that they were sexually active,
but monogamous with one partner in Moscow, usually another migrant.
These women reported that they were planning eventually to marry their
sexual partner, “My attitude towards sex is that if you trust and love
your boyfriend it is a benefit because the body requires it. When you
are with one man, it is good.” (Tajik, 19A). She continued saying,
“Many people have sex with condoms, but I think condoms are a
disrespect to your body. Why should I use a condom if I am having sex
with my love.” Another said, “I do not feel good when he uses condoms.
For me, when he uses condoms, it is like he keeps away from me. I feel
like he uses me if he uses a condom. Like, he would use condoms with
any girl” (Tajik, 22). Although the participants did not report
suspecting that their partners had sexual relations with other women or
sex workers, our knowledge suggests that this is very likely.11
although these women are currently monogamous, they are considered to
be at moderate HIV risk.
Currently Sexually Active, Transactional Sex or Sex Work
(Elevated Risk)
Four (13%) of the female migrants were involved in either transactional
sex (n=2) or sex work (n=2). The women who performed transactional sex
reported needing money or a place to stay. “In Russia, it is normal to
have sex for money, it is not shameful. Though for us it is shameful to
ask another for help this way” (Tajik, 33B). Their partners sometimes
included married migrant men and drug users. Both of the women engaged
in transactional sex reported always using condoms, “When I have sex I
use condoms, and thus I protect myself” (Tajik, 33A). The sex workers
reported working independently and saw mostly Russian men. Both of the
migrants who did sex work reported inconsistent condom use. One sex
worker always used a condom with her new clients, "They say they will
pay more if I refuse to use a condom, but I do not pay attention to
them. I say that I will use a condom. I understand that if I catch a
disease, this money will not be enough to get cured" (Kyrgyz, 30).
Another woman who did sex work said, "Sometimes I use condoms. If I
meet with a guy for the first time then I use it, but with the familiar
guys I do not. I can trust the familiar ones" (Tajik, 33B). Due to
their many concurrent sexual partners, and their inconsistent use of
condoms, these migrants are considered at elevated HIV risk.
Roles of Socio-Structural Barriers and Protective Factors
Qualitative findings were used to characterize the possible roles of
socio-structural barriers and protective factors.
Socio-Structural Barriers as Facilitators of Sexual Risk
Some female migrants lacked the proper documentation for migrants
living and working in Moscow. They most often mentioned problems
obtaining work permits and Moscow registration, stating they could not
afford to pay twelve thousand rubles (approximately $400) for a work
permit. One said, “To find work, you should have documentation,
registration, and work permission. I made a registration when I came,
but it was hard to do the work permission. I found that the work
permission is very expensive. I found that I have to pay for
everything, and it is difficult" (Kyrgyz, 30). Another reported, “When
you do all your documents then you will find a job. If you don’t you
won’t find a job” (Kyrgyz, 23B). Women said that without documents,
they were more likely to be arrested and detained by the police, who
would expect bribes or favors, or be sexually harassed and exploited by
employers, “If you have no documents, you have no freedom” (Kyrgyz,
27). Some women reported giving in to the sexual demands of their
employer in return for money.
Most female migrants reported lacking family or friends who could
provide them with financial, material, or other tangible support. One
stated, “I don’t have close friends in Moscow, just girls whom we live
together and we say each other just ‘hello’ and ‘goodbye’ and nothing
more. I don’t have close friends to share something with” (Tajik, 34).
Some women were recruited into sex work by female friends: “She did not
tell me directly, she just invited me to her apartment. There were two
men, and she introduced me to one. We talked and talked. She then said
that he will help me and give me money, and he did” (Tajik, 33B).
Cultural Attitudes as Protective Factors Against HIV Sexual
Risk
Some migrants who were not involved in transactional sex or sex work
expressed cultural attitudes towards sexual relations before marriage.
These cultural attitudes were found in both Tajik and Kyrgyz migrants.
One woman said, “I understand that at my age it is a normal time to
have sex. But according to our oriental mentality, I try to protect
myself from sexual contact till my wedding day” (Tajik, 27B). Another
stated, “I was brought up by my parents in a way that I can’t have
sexual relations with anybody until marriage. There can be anything
before marriage” (Kyrgyz, 27). Those migrants who did not pursue
transactional sex or sex work despite socio-structural barriers
reported more traditional cultural attitudes towards sex work, health,
and insecurity. Again, these cultural attitudes were also found in both
Tajik and Kyrgyz migrants. Several were unwilling to do sex work
because of its sinfulness. One stated, “I was offered several times but
it is a great sin, therefore I refused. I don’t want to make me
“haraam,” [Arabic for “forbidden”] the “haraam” money makes no sense
for me, and I don’t want to make my body dirty with dirty men” (Tajik,
31). Another stated, “I don’t want to do sex work; I want to earn my
salary honestly (Kyrgyz, 22).” Others reported worries over the
insecurity of transactional sex. One stated: “I know it is only
temporary. They will use you … kick you out …you will again be alone. I
do not want such things. I am only interested in my work” (Tajik, 27A).
Of course cultural attitudes would not necessarily protect female
migrants against forced sex, manipulation, or trafficking.
Hypothesized Pathways Involving Socio-Structural Barriers and
Protective Factors
Figure 1 represents hypothesized pathways connecting socio-structural
barriers, possible protective factors, current sexual activity, and
level of HIV sexual risk based upon the study findings.
Regarding risks, this figure indicates a hypothesized pathway linking
legal documentation and instrumental support with elevated sexual risk.
Specifically, four (100%) of the women in current transactional sex or
sex work had neither legal documentation nor instrumental support. In
comparison, 2 of 8 (25%) currently sexually active, monogamous, and 4
of 18 (22%) not currently sexual active lacked instrumental support and
legal status.
Regarding protective factors, this figure indicates how protective
factors may partly explain why some female migrants exposed to
socio-structural barriers exhibit none or moderate current sexual risk.
Specifically, of the 20 female migrants with either legal status or
instrumental support, 12 (60%) were not currently sexually active, one
possible indicator of protective factors. Of those 10 female migrants
lacking both legal status and instrumental support, 4 (40%) were not
currently sexually active, and 2 (20%) were currently sexually active
and monogamous, another possible indicator of protective factors.
Discussion
Central Asian female migrants in Moscow reported difficulties with
acquiring documents for legal status, financial insecurity,
discrimination, sexual harassment, and lack of support. These
difficulties are viewed as consequences of socio-structural barriers
which are shaped by underlying social, economic, and political
phenomena, not individual inadequacies. This study also found
qualitative evidence suggesting possible associations between
socio-structural barriers (e.g. lacking both legal status and
instrumental support) and current elevated HIV sexual risk.
The study findings indicated that socio-structural barriers did not
explain all HIV sexual risk. Some women were sexually active and
monogamous; however, their regular partners were migrants and thus
likely to be sexually active with multiple partners concurrently.11
Some women engaged in sex work or in transactional sex preferred not
using condoms, despite their knowledge of HIV/AIDS and HIV prevention
skills. This preference was especially true with regular clients, a
pattern which has been found elsewhere.22
Cultural attitudes regarding sex work, health, and insecurity could be
protective in female migrants who chose not to do sex work or
transactional sex. To lower risk behaviors, HIV preventive
interventions may try to facilitate changes in female migrants’
cultural attitudes. However, this intervention model is limited by its
focus on individual level change in ideology rather than contextual
changes; a limitation previously noted in U.S.-derived HIV preventive
interventions.37
Several additional policy and program steps are warranted. Through
bilateral agreements between the Russian Federation and Kyrgyzstan and
Tajikistan, legal steps could be taken to improve female migrants’
ability to obtain proper documentation for legal status in Russia, thus
enabling more to work and earn money through means other than sex work.
Health has been framed as a human right in multiple international human
rights treaties including the Convention on Elimination of
Discrimination Against Women (CEDAW), to which Russia, Tajikistan, and
Kyrgyzstan are each signatories. It stipulates the health rights of
labor migrants, including HIV prevention and care.38
This treaty
requires actions from each national government to protect female
migrants’ health rights through providing health and social services at
three times and locations: 1) prior to migration; 2) during their stay
in the receiving country; 3) upon reintegration in the sending
countries. In particular, HIV preventive interventions for female
migrants should be conducted in the sending countries both pre and post
migration, in transit, and in the receiving country. Another priority
is the establishment of community support networks in the receiving
country that would provide needed instrumental, social, and emotional
support for female migrants. This should include programs for income
generation through cooperatives that would protect female migrants from
unwilling entry into sex work or transactional sex, as well as to
assist those wanting to leave sex work or cease transactional sex.39
These health and social service initiatives are the responsibility of
the sending and receiving countries and require coordinated, joint
actions.
Regarding research implications, this study produced a model linking
health outcomes and social determinants that requires further
investigation in order to support new program and policy initiatives
for the growing global trend of female labor migrants who find
themselves in high risk environments. Key research questions regarding
female labor migrants include: Do socio-structural barriers predict
sexual risk? What is the protective role of cultural attitudes? What
are the pathways, over time, by which female migrants move into or out
of sexual risk behaviors? What socio-structural barriers and cultural
attitudes are potentially modifiable by multilevel interventions? How
can the constraints upon community leaders, organizations, and
policymakers best be managed? How can community collaborative
approaches best be used to develop, implement, and evaluate new
interventions and policies? Rigorous, longitudinal, mixed method
studies with both purposive and probabilistic samples are needed.
This study has several limitations. First, there is possibility of
misunderstanding due to interpretation. We addressed this challenge
through a multi-lingual research team and ongoing review of
translation. Second, the sample was not representative of the entire
female migrant population in Russia, which includes women from other
countries. Third, because participants were recruited through
organizations, those most isolated and perhaps with greater sexual risk
were not included. Fourth, because this study was cross-sectional, we
could not follow women’s actual pathways regarding migration and HIV
sexual risk over time. Fifth, because there sample was purposive and
the cells too small, we could not test the associations statistically.
Conclusions
This study addresses the understudied global phenomenon of the
feminization of labor migration and focuses on their HIV risk. It
builds knowledge regarding the unique multi-level contextual variables
involving structural, social, and cultural level factors that need to
be understood in developing HIV preventive intervention for sexually
active female migrants. Future HIV prevention efforts with Central
Asian female migrants in Moscow should focus on facilitating legal
status, building community support, promoting condom use with regular
partners, identifying and supporting cultural attitudes that protect
against HIV sexual risk behaviors, and rigorous research testing of
these hypothesized pathways.
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