Gendered livelihoods, mobility and health care engagement Presented at the 4th ASSHH Conference By Dr. Fortunate Shabalala (MPH, PhD) University of ESwatini 24.07.2018

Setting the context Gender has long been recognised as a KEY factor influencing how we live, engage with and relate to each other and our environment Gender influences our everyday decisions and practices we carry out to meet that which is expected of us as males and females, including mobility, livelihoods and engagement with health services such as those relating to HIV. Our livelihoods, or how we make a living, are central to who we are, where we fit into our society and into global systems, and our material wellbeing.

Setting the context A livelihood comprises the capabilities, assets (including both material and social resources) and activities required for a means of living The activities and tasks differ according to gender roles, which themselves are shaped by social, economic and political context Through our livelihoods we engage and interact both with other people and with our environments

Reasons for mobility The articles in the special issue suggest that men’s and women’s reasons for mobility differ, and have to do with the different livelihoods, choices and resources available to them; This affects their forms of mobility, with men migrating and travelling over longer distances and time periods while women migrate more locally and return more frequently Amongst other things, the mobility patterns of men and women affects the behaviours they engage in during the periods of absence. In their study, Camlin et al reports a high sexual concurrency in men than women, putting themselves and their partners at risk for STIs and HIV

Gendered livelihood, mobility and engagement with health care services Health is a resource required to carry out activities of daily living, however it also requires access to such resources as finance, time, decision-making power The decision to (dis) engage with health services, for instance, is much an outcome of social context as it is of capabilities and resources at person has at his/her disposal

Livelihoods, mobility and engagement with health care services Seeking and staying in HIV care is a tough decision that people have to balance with competing priorities of earning a means of living. This is particularly true in resource limited settings where livelihood mobility, either within or outside the community for shorter periods, or further afield for longer periods of time, is essential to get by In the articles by Shabalala et al, Bond et al and Camlin et al, we see how women and men would forgo their own health needs to engage in livelihood activities that will reap the ‘good life” for their families

Livelihoods , mobility and engagement with health care services Shabalala et al reports how being the sole provider influence a mother’s decision to forgo ART and prioritize children’s needs: “I had just started working after a long time without a job. Continuing with the pills would have meant I had to ask for a day off every month to go to the clinic…I feared that if I continued with the pills my employer would fire me. I couldn’t risk that…I have children to take care of. . . My husband died four years ago so I am their [children] only provider”

Livelihoods , mobility and engagement with health care services Bond et al reports how five of the six participants in their study had prioritized providing for their households and their dependents over their own health by taking deciding to delay, miss or stop taking treatment to make ends meet for their households: If I start now, where I go it is far and there is no ART centre. What happens when I run out of drugs? It is better I use my body to feed my family when I am still feeling strong.

Livelihoods, mobility and engagement with health services Clouse et al’s article shows how circumstances and maternal obligations “forced” women to jungle between their urban work-life and need for motherly care during delivery. They made decisions to travel to rural homes to seek care during delivery and of their babies post delivery. In some cases they chose to leave their infants with relatives (their own mothers or mothers-in-law) to return to work to earn a living for themselves and their babies There is no one here who can help me with the baby, so I want to be home with my mother (Clouse et al, 2018)

Livelihoods , mobility and engagement with health care services The need to make better returns led to participants travelling far from their usual place of aboard often for longer periods to areas where there are no ART services, resulting in disengagement from HIV care I lost my ART identification number, and where I went there are no ART services, and I fear going to a public health ART centre because they would tell me off for treatment disruption (Bond et al, 2018).

Key points The livelihood activities and tasks participants engage in differ according to roles and expectations, which themselves are shaped by social, economic and political context While the circumstances leading to eventual disengagement with health services are complex and varied, gender and livelihoods are common factors Participants prioritized providing for their households and their dependents over their own health by taking decisions to delay, miss or stop taking treatment

Key points Gender, livelihood are intertwined; mobility is the means to make livelihood, People travel close and far primarily to raise money to meet household basic needs, and prioritised livelihoods over their own health. Gap in current approaches to delivery of health services: access is only possible at certain geographic areas and certain times, thus affecting sustained engagement by and with clients Choiceless choice: delayed, intermittent engagement for some and disengagement for others.

Conclusion The articles demonstrate that participants’ reason for mobility was primarily to raise money for household basic needs such as food, children’s schooling, shelter and other social obligations. This need was prioritised over their own health. The articles also shows a gap in the organisation and/or delivery of health services: access is only possible at certain geographic areas and certain times, thus affecting sustained engagement by and with clients Re-orientation and reprogramming is needed to ensure retention and optimal adherence

References Bond et al (2018). Spinning the plates: Livelihood mobility, household responsibility and antiretroviral treatment in an urban Zambian community during the HPTN 071 (PopART) Study. Journal of the International AIDS Society 2018, 21(S4):e25117 Camlin et al (2018). Bringing population mobility into focus to achieve HIV prevention goals. Journal of the International AIDS Society 2018, 21(S4):e25136 Camlin et al (2018). Population mobility associated with higher risk sexual behaviour in eastern African communities participating in testing and treatment trial. Journal of the International AIDS Society 2018, 21(S4):e25115 Clouse et al (2018). I will leave the baby with my mother: long distance travel and follow up care among HIV positive pregnant and postpartum women in South African. Journal of the International AIDS Society 2018, 21(S4):e25121 Shabalala et al (2018). Understanding the reasons to discontinuing antiretroviral therapy among clients enrolled in test and treat: a qualitative study in Swaziland. Journal of the International AIDS Society 2018, 21(S4):e25120