This is the first study in Uganda to primarily investigate the nexus between rural-urban migration and SRH services utilisation among street children and young adults using quantitative methods, through the social ecological lens. Our study reveals rural-urban migration as a key determinant of SRH services use among street children and young adults in Kampala, with migrants being disproportionately affected compared to non-migrants. Other predictors of use of SRH services among street children and young adults included age, schooling status, access to SRH education and knowledge of a place of SRH care. Religion was a major predictor of use of contraception.
Returning to the question of whether rural-urban migration influences SRH services use, the low use of SRH services (HIV testing, STI screening and FP) among migrants compared to the non-migrants confirms our hypothesis that non-migrant street children and young adults are likely to have better use of SRH services than rural-urban migrants. It also demonstrates migration status as a barrier to access to and use of SRH services (HIV testing, STI screening and FP) among rural-urban migrant street children and young adults living in urban environments. This finding is plausible given the social context within which migrant street children and young adults live, adapt and socialise while on the streets of Kampala.
Conversely, the odds of using SRH services were 1.4 times higher among established migrants (> 2 years of stay in city) compared to new migrants (≤ 2 years of stay in city). It should be noted that street life is a process that requires adaptation to the new street environment, as the newcomers may take some time to establish social and peer support networks, which is critical for healthcare support. As such, street children and young adults especially established migrants must dully navigate the challenges of street while also adapting to the new street culture and language. Therefore, the newcomers may take some time to establish social and peer support networks which is critical for social support during healthcare seeking(42)(43).
Reduced utilisation of family planning especially among rural-urban migrant street young adults could potentially result into increased fertility that could further escalate the country’s annual population growth rate of 2.88%, which seems to be growing faster than government’s capacity to deliver vital services(44). However, this result contrasts sharply with the Kenyan study in which use of modern contraception was higher in migrants than non-migrant women(45). The difference with our findings could be attributed to different methods and study population used. Unlike our study, the Kenyan study utilised national demographic and health survey data of sexually active women of reproductive age group and looked at different migration streams, to explain the differences.
In our study, we observed an association between age and use of SRH services. This finding may suggest that older street young adults are stronger and therefore can navigate the complex urban health care system with ease compared to their young counterparts, who may require support from adults in seeking healthcare services. It is possible that older street young adults are involved in health compromising practices such as drugs, risky sexual behaviour and hence more likely to seek healthcare than the young street children.
The reduced odds of using SRH services especially HIV testing services among in-school street children and young adults as opposed to their out-of-school counterparts may suggest limited access to SRH information and services within the school environment due to restrictive policies. In Uganda, the current policy does not allow distribution of SRH commodities and hence prohibiting the sexually active learners within from accessing them within the school environment. Such restrictive educational policies that include sanctions against young people found to be in possession of condoms while in school hinder effective implementation sexual behaviour interventions in many low to middle income countries(46). When in school, the in-school street children may be omitted from SRH services that are provided to their out-of-school counterparts within urban community environment. Within the local context, with most street children being out-of-school, the community environment remains the most appropriate avenue for delivery of SRH information and services to this marginalised group of urban poor youth. Earlier studies have demonstrated the role of access to SRH information in contraceptive use among young people(47).
In our study, religion and not gender dynamics strongly influenced the uptake of family planning among street children and young adults. The low uptake of family planning among Christians compared to non-Christians could be attributed to the myths, misconceptions, cultural and religious beliefs about modern contraception which are widely held by many rural communities in Uganda from which the street children and young adults originate. Previous qualitative studies done in Uganda and Tanzania confirm religious and cultural beliefs remain an impediment to uptake of family planning methods among women and men of reproductive age(48)(49). This result suggests high unmet need for contraception among street young people and provides an opportunity for responders to engage urban street children and young adults on changing their religious perceptions and practices on modern contraceptives. Since young people are ardent followers of their faith leaders, involving the latter is critical in addressing the SRH rights and needs of street children and youth.
This study had some strengths and limitations. First, we were able to establish the association between rural-urban migration and use of SRH services among street children and young adults, as the main explanatory variable while controlling for confounding as guided by the study theory. Second, the use of a large sample size with adequate power to detect the minimum meaningful difference in establishing a relationship between predictors and use of SRH services is another strength. Our data are cross-sectional and therefore preclude our ability to determine the direction of causality. We did not control for sexual behaviours and participants’ household characteristics which might possibly confound the relationship between migration and SRH services use. However, the lack of a well-defined formal housing structure (temporary shelters) in which the street children and young adults live within urban spaces could not permit analysis of household characteristics.
The lack of an association between internal circular migration of street children and SRH services use could be attributed to limited opportunities to access to SRH and other support services during the migration process. Most circular migrants are also likely to be new migrants or stayed for a short time in the urban spaces and hence with low SRH services utilisation as revealed by the study findings. Available literature seem to report limited accessibility to health services among international migrants during the migration cycle or integration in host communities(24). The importance of research on implications of rural-urban circular migration of limiting access to SRH services in the context of rural-urban migration require further exploration.
It is probable that migrant street young adults could have used contraceptives prior to migration, in which case, the results of our study could overestimate contraceptive use among migrants. However, we did not find a significant association in the use of FP services between new migrants (≤ 2 years of stay in city) and established migrants (> 2 years of stay in city). Therefore, it is unlikely that use of contraceptives among street children and young adults prior to migrating to Kampala would substantially influence estimates of FP services utilisation in our study sample. Moreover, results from nationally representative population-based surveys of 15-24 year-olds show that contraceptive services are still underutilized in rural areas of Uganda(50). Given the fact that all regions of Uganda have experienced rural-urban migration of street children and young adults, we believe that our study findings could be generalisable to all street children and young adults in Ugandan cities.
As a final note on the study theoretical underpinning, our study findings illustrate the synergetic relationship between individuals, interpersonal and their social environment factors which interact to influence the use of SRH services among the street children and young adults through the social ecological lens. Previous research on SRH services utilisation have adopted the socio-ecological model(51). Our finding on low utilisation of SRH services among new and established migrant street children and young adults compared to the lifelong native street children contrasts with the healthy migrant effect model which posits that, over time, individuals who migrate could have healthier behaviours than the native population(29). Lastly, this study provides new knowledge on the understanding of the nexus of rural-urban migration and SRH services utilisation among street children and young adults in Kampala, Uganda. It highlights the need for future research on the impact of rural-urban migration on street children and young adults’ SRH behaviour and outcomes.