PLOS ONE
STUDY PROTOCOL
Interventions impacting the accessibility of
sexual reproductive health services for head
porters in sub-Saharan Africa- A scoping
review protocol
Kimberly Jarvis 1,2 2,3 4 5ID *, Solina Richter , Samuel Adjorlolo , Michelle SwabID ,
Eric Tenkorang6, Yuping Mao7, Laura A. Chubb 8ID , Charles Ampong Adjei
9,
William Midodzi5, Adom Manu10, Kwasi Torpey 10ID , Cara Spence
11, Pammla Petrucka2
a1111111111 1 Faculty of Nursing, Memorial University of Newfoundland, Newfoundland, Canada, 2 College of Nursing,
a1111111111 University of Saskatchewan, Saskatoon, Canada, 3 Research Fellow Department of Health Studies,
a1111111111 University of South Africa, Pretoria, South Africa, 4 Department of Mental Health, University of Ghana, Accra,
a1111111111 Ghana, 5 Faculty of Medicine, Memorial University of Newfoundland, Newfoundland, Canada, 6 Department
a1111111111 of Sociology, Memorial University of Newfoundland, Newfoundland, Canada, 7 Department of
Communication Studies, California State University, Long Beach, California, United States of America,
8 Faculty of Education and Social Work, University of Auckland, Auckland, New Zealand, 9 Department of
Public Health Nursing, University of Ghana, Accra, Ghana, 10 Department of Population, Family and
Reproductive Health at the School of Public Health, University of Ghana, Accra, Ghana, 11 Department of
Medicine, University of Saskatchewan, Saskatoon, Canada
OPEN ACCESS
* kimberly.jarvis@mun.ca
Citation: Jarvis K, Richter S, Adjorlolo S, Swab M,
Tenkorang E, Mao Y, et al. (2023) Interventions
impacting the accessibility of sexual reproductive
health services for head porters in sub-Saharan Abstract
Africa- A scoping review protocol. PLoS ONE
18(8): e0289564. https://doi.org/10.1371/journal. Head porters working in markets in sub-Saharan Africa (SSA) are one of the world’s most
pone.0289564 vulnerable and socioeconomically disadvantaged groups. They consist predominantly of
Editor: Olushayo Oluseun Olu, World Health uneducated women and girls seeking to escape poverty, early marriage, and other issues
Organization, SOUTH SUDAN of domestic violence. Most female head porters are in their reproductive years and often
Received: January 20, 2023 lack access to sexual reproductive health services (SRHS) despite being at high risk for
sexually transmitted infections (STIs), unplanned pregnancies, and gender-based vio-
Accepted: July 21, 2023
lence. The low priority for women and girls’ SRH in many SSA countries highlights the
Published: August 18, 2023
need to explore the factors influencing the accessibility of services for failure to do so
Copyright: © 2023 Jarvis et al. This is an open restrains human development. An initial search of the literature was conducted and
access article distributed under the terms of the
revealed no current scoping or systematic reviews on the accessibility to SRHS for
Creative Commons Attribution License, which
permits unrestricted use, distribution, and female head porters in SSA. We outline a scoping review protocol, using the Joanna
reproduction in any medium, provided the original Briggs Institute methodology, to determine the interventions that influence the accessibil-
author and source are credited.
ity of SRHS for female head porters in SSA. The protocol is registered with Open Science
Data Availability Statement: This is a scoping Framework (https://osf.io/hjfkd). Findings will not only be valuable for female head por-
review protocol. Currently there is no data
ters but for all vulnerable female groups in SSA who experience high SRH risks and
available. Research data will be made publicly
available when the study is completed and social disparities.
published.
Funding: The author(s) received a CIHR Bridging
Fund: University of Saskatchewan for this work.
Competing interests: The authors have declared
that no competing interests exist.
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PLOS ONE Interventions impacting the accessibility of sexual reproductive health services for head porters
Introduction
Head porters working in markets in sub-Saharan Africa (SSA) are one of the most vulnerable
groups. They consist predominantly of women who have migrated from the impoverished
regions in SSA to more affluent urban areas, seeking to escape poverty, early marriage, and
issues of gender-based violence [1, 2]. Head porters carry loads on their heads and have locally
designated/acquired names unique to the various countries in SSA. In Ghana, for example,
head porters are called ‘kayayei’; while in Nigeria, they are referred to as ‘alabaru’ [1, 3]. Male
porterage also exists but they mainly push ‘pulling trucks’ and generally do not carry loads on
their heads. The number of head porters in any geographical area is often unknown, as the
‘trade’ is not regulated in SSA. In 2017, it was estimated that 160,000 head porters resided in
Accra, Ghana with 15,000 more young women predicted to enter the occupation yearly [4].
Head porterage is a strategy for economic survival [5, 6]. Head porters work in markets, deliv-
ery stations, and/or car parks where their services are needed, carrying goods, and belongings
for a fee [7]. Typically, they carry more than their own weight on their heads from dusk to dawn,
up and down the maze of what constitutions the market area. Working as a head porter is con-
sidered profitable, which encourages women to migrate to ‘richer’ urban centers to earn a mea-
ger living [8]. Due to their disadvantaged socioeconomic background, head porters often feel
obligated to meet the financial needs of their kin and subsequently remit portions of their earn-
ings to support their families. Additionally, some supplement their daily earnings by engaging in
nocturnal sex work when the ‘normal day’s work’ is over. This survival strategy places them at
risk for sexually transmitted infections (STIs), hygiene-related illnesses, gender-based and sexual
violence such as rape, unplanned pregnancies, illegal abortions, and human trafficking [9].
Most head porters are uneducated, unskilled migrant women in their reproductive ages,
between 15 and 49 years, who often lack access to SRHS [7, 8]. This neglected service affects
their physical, psychological, sexual, and socioeconomic health and wellbeing. Evidence sug-
gests that women commonly experience exploitation at the hands of their employers, as well
as, landlords, police, commercial vehicle drivers (taxi and delivery trucks), and city guards that
are employed by the local government to regulate and enforce rules in the markets [10]. Power
inequities undeniably exist when female head porters depend on these individuals, who are
often men, for their survival and wellbeing.
The literature suggests that head porters’ knowledge of SRH are low, and their access to and
utilization of health services are poor [10–12]. While constraints to basic and fundamental
SRHS are often rooted in insufficient financial and systematic resources, such as infrastructure
and a well-functioning health system, other reasons exist that impacts access [13–15]. Access
to SRHS is often limited, for example, by cultural inhibitions, perceived negative consequences
arising from the use of contraceptives, especially injectable and intrauterine devices [16], fear
and embarrassment of being seen at a health facility when such services are socially unaccept-
able as well as negative attitudes of health care providers [17].
The lack of access to SRHS is compounded by recurring epidemics and/or pandemics. Dur-
ing public health emergencies, human and financial resources are diverted from various health
programs to respond to the crisis. This sudden diversion of resources negatively affects the
delivery of SRHS as demonstrated during the recent coronavirus (COVID-19) pandemic [17,
18]. Since the pandemic, there has been decreased access to basic SRHS, and increased viola-
tions of SRH rights, while the risk for gender-based and sexual violence has significantly
increased by an estimated 30% in some SSA countries [17]. It is important to consider this
while acknowledging the low priority for women and girls’ SRH in many SSA countries. His-
torically, many SSA countries are patriarchal societies where women experience SRH inequal-
ity and inadequate access to SRHS [18].
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PLOS ONE Interventions impacting the accessibility of sexual reproductive health services for head porters
The profound and measurable benefits of attending to women and girls’ SRH are linked
to “gender equality and women’s wellbeing, their impact on maternal, newborn, child, and
adolescent health, and their roles in shaping future economic development and environ-
mental sustainability” [19, p.2642]. It is further argued that individuals have the right to
make decisions related to their bodies that are “free of stigma, discrimination, and coercion.
These decisions include those related to sexuality, reproduction, and the use of SRHS” [19,
p.2642]. According to the United Nations 2030 Sustainable Development Goals (SDGs),
accessibility to SRHS is essential for sustainable development [20]. Specifically, SDG 3; good
health and wellbeing, targets 3.7 and 3.8 are important because they ensure “universal access
to SRH care services” [20, goal 3 targets. para, 11] and “universal health coverage . . .for all”
[20, goal 3 targets. para, 12]. A 2018 report in the Lancet recommended that countries
should include SRH as an essential service within the universal health coverage palette with
special attention to the poorest and most vulnerable [21]. The World Health Organization
(WHO) is striving
for a world where all women’s and men’s rights to enjoy sexual and reproductive health are
promoted and protected, and all women and men, including adolescents and those who are
underserved or marginalized, have access to sexual and reproductive health information
and services
[22, para.2].
In many SSA countries, migrant female head porters may be displaced and have unsafe
housing, and working conditions as their employers frequently have power over them, inhibit-
ing their access to needed resources. Additionally, as previously mentioned, these women also
experience gender-based violence, unplanned pregnancies, and STIs [9]. This places head por-
ters in what some may call a ‘precarious environment’ [2]. Improving SRH access and out-
comes (particularly to contraception and women’s empowerment) is essential to achieving
population health.
The Minimum Initial Service Package (MISP), is an approach designed by a global coali-
tion, the Inter-Agency Working Group for Reproductive Health in Crisis, to advance compre-
hensive SRH and SRH rights in precarious environments [23]. This review will use this
approach as a guide for extracting data since female migrant head porters are often in unstable
environments which threaten access to SRHS. The MISP objectives include:
• “Ensure the health sector identifies an organization to lead the implementation of the MISP,
• Prevent sexual violence and respond to the needs of survivors,
• Prevent the transmission of and reduce morbidity and mortality due to HIV and other STIs,
• Prevent excess maternal and newborn morbidity and mortality,
• Prevent unintended pregnancies,
• Plan for comprehensive SRH services, integrated into primary health care” [23, para. 4].
Despite limited interventions specifically targeting head porters [24, 25] there are
numerous efforts directed towards vulnerable women and girls with unmet SRH needs in
SSA.
Educational, community-based, primary prevention, empowerment-based, psychological/
counseling, income generating training programs, and development of SRH risk-reduction
messages are the SRH interventions found in the literature [26–32]. Additionally, the use of
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PLOS ONE Interventions impacting the accessibility of sexual reproductive health services for head porters
medicine shops/vendors as an alternative for accessing family planning methods was advanced
as an intervention to increase access to SRHS [33, 34]. The identification of gaps and knowl-
edge of what SRHS are available and why current interventions succeed or fail, can set the
foundation for improved SRH outcomes and access to services. An initial search found no cur-
rent scoping or systematic reviews in PROSPERO, MEDLINE, the Cochrane Database of Sys-
tematic Reviews, or the Joanna Briggs Institute (JBI) Evidence Synthesis. There is an urgent
need to conduct a scoping review on the SRH service interventions’ accessibility to female
head porters in SSA because the health of women and girls is relevant to promoting human
development (i.e., gender equality, agency, good health for all, etc.,) [35]. The findings of this
review would be valuable to not only head porters, but all vulnerable women groups in SSA
needing to access SRHS since the root cause of inadequate access to SRHS is often linked to
gendered issues, power imbalances, and social disparities.
Material and methods
The Joanna Briggs Institute methodology for scoping reviews [36] will be utilized in this
review. The protocol is registered with Open Science Framework (https://osf.io/hjfkd).
Review question(s)
What interventions impact the accessibility of SRHS for head porters in sub-Saharan Africa?
Inclusion and exclusion criteria
The following is a described list of inclusion criteria. All other articles will be excluded from
this review.
Participants. This review will be taken into consideration papers that include female head
porters who work in SSA markets carrying goods and wares on their heads from one location
to another for a fee. While traditionally both males and females participate in head porterage,
only females will be considered since they comprise most of the workforce and have SRH
needs that differ from their male counterparts.
Concept. Accessibility of SRH interventions for head porters is the concept being exam-
ined in this scoping review. For the purpose of this review, we define access as: 1. “affordabil-
ity (direct and indirect cost of health), 2. physical accessibility (e.g., opening hours,
geographical placement/reach), 3. acceptability (e.g., willingness to seek services), and 4.
social or cultural factors (e.g., language or the age, sex, ethnicity, or religion of the health
provider)” [37, para.4].
The types of interventions considered in this review are primary (health promoting, pre-
venting disease or injury), secondary (early detection of a disease or injury or preventing it
from becoming worst), and tertiary (managing a disease or injury) SRH interventions. We
further adopted the 2021 United Nations Population Fund (UNFPA) definition for good
SRH as:
a state of complete physical, mental, and social well-being in all matters relating to the
reproductive system. It implies that people are able to have a satisfying and safe sex life, the
capability to reproduce, and the freedom to decide if, when, and how often to do so. To
maintain one’s sexual and reproductive health, people need access to accurate information
and the safe, effective, affordable, and acceptable contraception method of their choice.
They must be informed and empowered to protect themselves from sexually transmitted
infections. And when they decide to have children, women must have access to services that
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PLOS ONE Interventions impacting the accessibility of sexual reproductive health services for head porters
can help them have a fit pregnancy, safe delivery, and healthy baby. Every individual has the
right to make their not own choices about their sexual and reproductive health
[38, para.1].
Context. This review will consider papers that discuss the impact of head porterage on
females who work in urban and rural African SSA markets. A total of 42 SSA countries and six
island nations will be included [39, 40].
Types of sources. Quantitative, qualitative, and mixed method studies, program evalua-
tions, quality improvement reports, dissertations, theses, peer reviewed conference papers, and
opinion pieces will be considered for inclusion.
Unpublished reports will be incorporated in this review but will be limited to national and
international governmental and non-governmental websites, which work with women in SSA
around SRHS, such as the WHO and the United Nations Population Fund (UNFPA).
Acknowledging the substantial attention to head porterage in SSA since the mid-1980s and
the advocacy for women and girl’s SRH rights and interventions during the era targeting the
United Nations 2000 Millennium Development Goals [41], studies published between 2000 to
2023 will be included. French, English, and Portuguese articles will be included as many SSA
countries speak these languages, in addition to their mother tongue.
Search strategy. The search for evidence will be conducted by the library scientist on the
review team, in consultation with other team members. The aim of the search strategy is to
find both published and unpublished studies. The search will include a variety of subject data-
bases in the medical and social sciences fields, such as:
• Ovid Medline
• Embase (via embase.com)
• CINAHL Plus (via EBSCOhost)
• APA PsycInfo (via EBSCOhost)
• Anthropology Plus (via EBSCOhost)
• ERIC (via EBSCOhost)
• SocINDEX (via EBSCOhost)
• Women’s Studies International (via EBSCOhost)
• International bibliography of the social sciences (via ProQuest)
Keywords and controlled vocabulary search terms were selected in consultation with a
subject expert and were revised based on preliminary search results. Given the results of the
draft search strategy in Ovid Medline, it is anticipated that many articles and reports relating
to this topic will not be indexed in the subject databases. Therefore, extensive Google Scholar
searches will be conducted to capture this literature. Google Scholar is the most inclusive
and comprehensive of the major academic literature indexes. Forward and backward cita-
tion tracing will also be of crucial importance and will be conducted for all included studies.
Backward citation tracing involves a review of reference lists of all included studies. Forward
citation tracing looks at citing articles and will again be conducted in Google Scholar. The
search for grey literature and unindexed studies will include the following websites and
platforms:
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PLOS ONE Interventions impacting the accessibility of sexual reproductive health services for head porters
• ProQuest Dissertations and Theses
• OATD: Open Access Theses and Dissertations
• Bielefeld Academic Search Engine
• OAIster
• OpenGrey
• African Journals Online
• African Index Medicus (AIM)
• ELDIS
Draft searches can be found in supporting information S1 File: Search strategy in Ovid
Medline and S2 File: Search strategy of preliminary grey literature. Following the search,
citations will be uploaded into Endnote X8, and duplicates removed. The remaining cita-
tions will be uploaded to Covidence. Titles and abstracts will be checked against the inclu-
sion criteria by two independent reviewers. To ensure agreement among the reviewers, the
first 50 titles and abstracts will be pilot tested. Only relevant papers will be reviewed in full
text by two independent reviewers and the reasons for exclusion will be noted and recorded
in the final report. Disagreements that arise at any stage of the screening process will be
addressed by way of a third reviewer or through discussion. Disagreements will provide the
chance to reinforce the screening process and inclusion criteria. The PRISMA Extension for
Scoping Reviews (PRISMA-ScR) [42] flow diagram will be used to display the search results
in the final report.
Data extraction. At the start of data extraction, all reviewers will review and extract data
for the first 10 papers to ensure consistency and clarity between reviewers using the data
extraction tool developed in supporting information S3 File: Data extraction instrument. Once
data extraction issues are resolved, data will be extracted from all included papers by two inde-
pendent reviewers in accordance with JBI methodology. The following data will be extracted,
as applicable: author(s), year of publication, the purpose of the study, study design, target pop-
ulation characteristics /sample size, study setting/location, study intervention details as well as
gaps, key findings, and study recommendations.
A third reviewer will decide on any disagreements. Authors, of included articles, will be
contacted when deemed necessary (i.e., missing data). All necessary revisions throughout the
data extraction process will be noted in the scoping review report.
Data analysis and presentation. The extracted data will be displayed in a table, supple-
mented with a descriptive summary, aligning with the objectives of this scoping review. Results
will provide the foundational knowledge for future interventions addressing the accessibility
of SRHS for head porters in SSA.
Supporting information
S1 File. Search strategy in Ovid Medline.
(DOCX)
S2 File. Search strategy of preliminary grey literature.
(DOCX)
S3 File. Data extraction instrument.
(DOCX)
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PLOS ONE Interventions impacting the accessibility of sexual reproductive health services for head porters
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses exten-
sion for Scoping Reviews (PRISMA-ScR) checklist.
(PDF)
Author Contributions
Conceptualization: Kimberly Jarvis, Solina Richter, Samuel Adjorlolo.
Methodology: Kimberly Jarvis, Michelle Swab.
Writing – original draft: Kimberly Jarvis, Solina Richter.
Writing – review & editing: Samuel Adjorlolo, Michelle Swab, Eric Tenkorang, Yuping Mao,
Laura A. Chubb, Charles Ampong Adjei, William Midodzi, Adom Manu, Kwasi Torpey,
Cara Spence, Pammla Petrucka.
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