Navigating Uncertainty: Exploring the links between Precarious Living Conditions and Health outcomes of Transit Refugee Women in Indonesia

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Among those in transit, women face distinct vulnerabilities shaped by gendered risks, limited access to legal protection, and barriers to essential services, making their living conditions and health outcomes particularly precarious. Using a participatory phenomenological approach, this study explored the lived experiences of refugee women in transit in Indonesia, focusing on how their precarious housing and living conditions shaped their health outcomes. The research consisted of four focus group discussions and eight in-depth interviews, involving women from Afghanistan, Somalia, Sudan, Sri Lanka, Yemen, Pakistan, Egypt, Palestine, and Eritrea. The study was conducted in collaboration with a community organisation led by and for refugee women in transit in Indonesia. Findings revealed that women’s precarious living conditions and health outcomes were closely tied to the access and availability of support services, including having registered humanitarian cards that provided varying levels of healthcare, food assistance, cash aid, and housing support. However, not all participants were registered, and eligibility criteria for registration to receive humanitarian support differed, resulting in unequal affordability and access to essential healthcare—particularly sexual and reproductive health services such as pregnancy care, menstrual health, family planning and contraceptives, mental health support, and management of chronic diseases like tumours and diabetes. These disparities often led to delayed or foregone medical check-ups, including tumour screenings, trauma counselling, and antenatal care. Some women experienced pregnancy complications, miscarriages, or postpartum health issues, with heightened risks for those who had undergone female genital mutilation before their transit journey. Housing conditions—whether supported by humanitarian assistance, reliant on private rental, or marked by homelessness—further shaped their health outcomes. Overcrowded living arrangements increased disease transmission, while inadequate water and sanitation, exposure to sexual and gender-based violence, and persistent mental distress, compounded their vulnerabilities. The study informs the need for greater efforts to implement gender-responsive policies and health programs that ensure refugee women’s safety and equitable and comprehensive access to health and housing support, particularly in precarious transit conditions. Transit refugee women sexual and reproductive health gender-based violence precarious living conditions health equity Introduction Forced displacement has reached unprecedented levels, with over 117 million individuals forcibly displaced due to conflict, famine, human rights violations, persecution, and environmental crises [ 1 ]. Among them, transit refugees constitute a significant but often overlooked subcategory. Transit refugees are individuals who have fled their countries and lacking legal protection, including those without asylum seeker status, a valid refugee visa, or whose documentation has expired and/or awaiting sponsorship. They remain in a state of temporary or legal limbo in transit locations while seeking safety and stability in host countries [ 2 , 3 ]. Yet, the absence of a universally accepted definition for transit refugees complicates both academic discourse and policy responses, leaving many in prolonged uncertainty [ 4 ]. Women represent a majority of the global refugee population, yet their specific experiences and vulnerabilities remain underexplored [ 5 , 6 ]. Across the migration journey—from leaving their home countries to travelling through transit locations and resettling in host countries —displacement exacerbates existing gender inequalities [ 6 , 7 ]. This exposure heightens their risk of sexual and gender-based violence (SGBV), economic marginalization, and restricted access to healthcare and legal protection [ 7 , 8 ]. Despite these challenges, migration policies fail to incorporate a gender-responsive approach, further marginalizing transit refugee women within refugee and resettlement contexts [ 7 , 8 ]. And, understanding these gendered dimensions of displacement, particularly from a health perspective, requires a broader examination of the social determinants of health that shape refugees' wellbeing, particularly in transit situations. Social determinants of transit refugee women For refugee women, the social determinants are shaped by displacement, legal status, and transit countries’ immigration policies, which highlight significant socioeconomic inequities, poverty, inadequate living conditions, and consequential poor health outcomes and inequity in healthcare delivery [ 8 ]. The financial constraints, legal restrictions, stigmatization, and language barriers they face when accessing healthcare and services, contribute to their poor physical and surging mental ill health [ 8 , 9 ]. The neglect of sexual and reproductive health and rights (SRHR) for transit refugee women has profound consequences, including poor family planning, limited access to contraceptives, inadequate abortion care, insufficient maternal and child birthing care, and weak prevention and control of HIV and sexually transmitted infections (STIs) [ 8 , 9 ]. This neglect has contributed to high rates of miscarriages, stillbirths, unintended pregnancies, and the spread of STIs and HIV, alongside the high prevalence of SGBV, particularly among girls and women within these contexts [ 8 , 9 , 10 ]. These health needs and healthcare disparities are also linked to the living environments and housing models made available to refugees, which vary based on national policies and the countries’ signatory status to the 1951 Refugee Convention and its 1967 Protocol [ 11 ]. Camp-based models are where refugees typically live in designated, enclosed sites administered by humanitarian agencies or host governments. These settings may offer structured services, including primary health care with components of sexual and reproductive health (i.e., the minimum initial service package), water, and sanitation, through coordinated aid, but can also impose restrictions on their mobility, privacy and economic autonomy [ 12 ]. By contrast, community-based living arrangements allow refugees to live among local host populations, offering independence, mobility, and social integration, yet with limited or fragmented access to formal protection and services such as healthcare [ 13 ]. These varying housing models and precarious living conditions negatively impact women’s health outcomes and their access to essential healthcare and treatment in distinct ways. Overcrowding, inadequate housing, poor sanitation, and lack of clean water, increase the risk and spread of infectious diseases, with high food insecurity leading to malnutrition, and chronic disease mismanagement [ 8 , 14 ]. Mental health, including depression, anxiety, and post-traumatic stress disorder (PTSD), alongside the elevated risk of sexual violence, risk of suicide, is also found to be higher among migrants and refugees in transit, compared to the host populations of these contexts [ 15 ]. Refugees in transit in Indonesia Southeast Asia is a critical transit region for refugees traveling from Africa, the Middle East, and South Asia. Countries such as Malaysia, Indonesia, and Thailand serve as key transit points in the region [ 16 ]. However, these nations vary in their legal frameworks and policies toward refugees, often influenced by their non-signatory status to the 1951 Refugee Convention and its 1967 Protocol . Indonesia, which is not a signatory to the Convention, does not provide formal legal recognition or protection for refugees. As a result, most transit refugees, who often come from Afghanistan, Myanmar (Rohingya), Somalia, Iraq, Sudan, and Sri Lanka, remain in prolonged uncertainty [ 16 , 17 ]. With limited national asylum laws [ 18 ], refugee status in Indonesia is determined by the United Nations High Commissioner for Refugees (UNHCR), which grants recognition but does not provide pathways to permanent resettlement within the country [ 16 – 18 ]. Due to their lack of legal status, refugees are legally not permitted to work, can only access public schools where there is availability, and are not financially supported to access public health services in Indonesia [ 18 ]. This legal limbo forces many to rely on limited international aid, informal and sex work, and community support for survival [ 18 , 19 ]. The Indonesian government permits refugees to reside in different models of accommodations, such as community housing funded by humanitarian organizations such as the UNHCR and the International Organization for Migration (IOM), or self-funded private housing [ 16 , 17 , 18 ]. However, livelihood resources are often inadequate, with poor living conditions, persisting health challenges, and long waiting periods for resettlement, sometimes lasting over a decade [ 16 , 17 ]. Transit refugee women in Southeast Asia experience significant health challenges, particularly in sexual and reproductive health and mental well-being, shaped by structural barriers such as limited healthcare access, financial hardship due to constrained humanitarian aid, and sociocultural stigma [ 10 ]. These challenges were further compounded during the COVID-19 pandemic, with many urban refugees, stateless persons and asylum seekers, often being excluded from vaccination programs, routine screenings, and access to basic healthcare. [ 19 , 20 ]. Given this context and with the growing number of refugees currently living in transit and entering Indonesia, it is crucial to understand how their living conditions impact their health outcomes. While existing research highlights the legal and humanitarian challenges refugees face in precarious living conditions, less is known about how these precarious housing and lived experiences determine their health outcomes, particularly for women within Indonesia’s legal and policy framework. Therefore, this study explored the lived experiences of transit refugee women in Indonesia, focusing on how housing and living conditions shape their health outcomes. Methods This study employed a participatory qualitative research design to explore the lived experiences of transit refugee women in Indonesia. A phenomenological approach was used to gain in-depth insights into their social determinants of health, particularly how their housing and accommodation arrangements, and living conditions shaped their health outcomes, access to healthcare, and health experiences in Indonesia’s transit context [ 21 , 22 ]. The participatory approach enabled collaboration with a refugee women’s community centre, which co-designed the study’s objectives and outcomes, co-created the data collection tools, contributed to data collection—including recruitment—and facilitated the dissemination of outputs. Additionally, the community centre provided a safe space for data collection. Participant recruitment and sampling Through our research collaboration, the community centre facilitated recruitment of study participants, who were selected using purposive sampling, followed by snowball sampling. This approach enabled the inclusion of participants with diverse backgrounds, including varying migration histories, lengths of transit in Indonesia, access to healthcare services, and health experiences. To be eligible, participants had to be refugee women currently residing under transit status in the Greater Jakarta area in Indonesia, aged 18 years or older, and willing to provide informed consent (see Table 1 ). A total of 27 participants took part in the study. Table 1 Summary of study participants Participant characteristics Percentage Country of origin Afghanistan: 37% Somalia: 30% Yemen: 7% Sudan: 7% Sri Lanka: 4% Pakistan: 4% Egypt: 4% Palestine: 4% Eritrea: 4% Native language Arabic Yemeni Sinhalese Farsi Somali Age group (years) 18–21: 0 21–35 : 85% 36–50 : 11% 51–65 : 4% 65+ : 0 Level of education No education: 7% Primary education only: 15% Secondary education only: 48% Tertiary education: 30% Family structure Single and living alone: 19% Single and living with parents/ in a family unit: 22% Single and living with friend(s): 4% Married and living with family: 56% Number of children No children: 52% 1 child: 15% 2 children: 22% 3 + children: 11% Housing/ accommodation model IOM-provided shelter: 30% Private rental: 67% Without shelter/ homeless: 4% Length of transit in Indonesia 0–2 years: 7% 3–5 years: 15% 6–8 years: 44% 9–11 years: 30% 12 + years: 4% Registered with UNHCR Yes: 100% No: - Receiving cash assistance Yes: 30% No: 70% Data collection methods Data were collected using two qualitative tools: focus group discussions (FGDs) and in-depth semi-structured interviews. FGDs provided insight into shared experiences, collective challenges, and coping strategies among refugees. A total of four FGDs were conducted, each consisting of 4–5 participants, categorized according to country of origin and region (i.e., Middle Eastern, African, South Asia), and preferred language (Arabic, Farsi, Somali). In addition to the FGDs, one-on-one in-depth interviews were conducted to gain deeper insights into personal experiences that may not have emerged during the FGDs. A total of 8 in-depth interviews were carried out with selected FGD participants and newly recruited participants. Both the in-depth interviews and the FGDs used the same semi-structured discussion guide, which helped to facilitate conversations on several key themes: living conditions and housing arrangements, health status and access to healthcare, food security, mental health, and interactions with humanitarian organizations in Indonesia. Probing questions were used to gather further insights. All FGDs and in-depth interviews were held in the community centre, which provided a neutral and safe location, with interpreters available to ensure effective communication in participants’ preferred languages. Ethical approval s for the study were obtained from the Monash University Human Research Ethics Committee (MUHREC) and in-country approvals from the National Research and Innovation Agency of Indonesia (BRIN). All participants provided informed consent before participation. Confidentiality and anonymity were strictly maintained, with identifying details removed from transcripts and pseudonyms assigned. Given the sensitive nature of the discussions, participants were provided with information about free, affordable mental health support services located in Jakarta, Indonesia, as needed. Data analysis Some of the FGDs and interviews were audio-recorded with participants’ consent and transcribed verbatim to English. However, some of the participants refused for their interviews to be audio-recorded, but agreed to have their information recorded by note-takers. All recordings and notes were translated and transcribed verbatim into English. Following Braun and Clarke (2006), thematic analysis was conducted with manual coding and the identification of the themes emerging from the data [ 23 ]. A data analysis and validation of findings were workshopped with selected study participants, and our research collaborators - members from the community centre. This helped to develop the coding framework, which was used to analyse the data. All transcripts were independently coded by two researchers to enhance inter-coder reliability. Any discrepancies were resolved through discussion to ensure consistency and validity in the analysis. Reflexivity and researcher positionality We acknowledge that none of the researchers have lived experience of forced migration or being transit refugees. Therefore, adopting a participatory approach—through collaboration with Indonesia’s only women-led refugee community organisation—was essential. This included co-designing the study design, data collection protocols and tools, and the dissemination of findings (including co-authorship of research outputs). Reflexivity was maintained through researcher's journals, documenting biases and assumptions that could influence the study. To increase the credibility and rigour of this work, we workshopped the preliminary findings with a group of transit refugee participants, including the founding members of the women-led refugee organization. This member-checking process ensured that our interpretations accurately reflected participants' lived experiences, fostered collaborative knowledge production, and strengthened the study’s methodological integrity. Results The findings of this study highlight the multiple and intersecting challenges that transit refugee women face in accessing healthcare, securing adequate accommodation, and managing their living conditions. A central theme that emerged was the restricted access to healthcare, which was closely linked to the type of humanitarian support they received, which determined their access to timely medicine/ treatment and specialist services. The analysis also revealed that housing and accommodation models played a significant role in shaping their living conditions, which further negatively influenced and exacerbated their physical and mental health outcomes. Intersectional factors such as women's age, family structure, country of origin, and native language played a crucial role in shaping their healthcare experiences. These factors influenced access to healthcare due to language barriers, experiences of violence and discrimination by healthcare professionals, which contributed to the worsening of health issues while living in transit. Persisting health challenges and financial hardship A common theme that was discussed was women’s sexual and reproductive health and rights, and a majority of the women reported that they experienced significant issues related to their menstrual health and hygiene. Due to financial hardship, many were forced to use a single sanitary pad for an entire day during their menstrual cycle, increasing the risk of infections and discomfort. Limited access to free and proper menstrual hygiene products and inadequate sanitation facilities further exacerbated these issues. Menstrual health problems are common among us women, and there’s high rates of infection and UTIs, and infection risks due to extended use of sanitary pads… Sometimes, they’d use just one sanitary napkin for an entire day, as refugee women can't afford enough supplies… Since UNHCR and partners stopped the support for supplies last year, this situation is worse for us… (FGD discussion, country: Somalia) Additionally, while some reproductive-aged women had access to family planning and contraceptives (e.g., IUDs), they lacked adequate health information and understanding about these methods, and in some cases, contraceptives were inserted without their full knowledge, particularly post-pregnancy or miscarriage. Many women also experienced pregnancy complications and miscarriages due to the lack of adequate ante- and post-natal care. High out-of-pocket (OOP) expenses, coupled with limited financial coverage provided by humanitarian assistance programs, limited their access to essential maternal health services. Under the current healthcare provisions, women were only able to access reproductive health services at the time of childbirth, as delivery was categorized as an emergency condition. However, routine antenatal care, which is crucial for preventing pregnancy-related complications and ensuring maternal and child health, remained largely inaccessible. …I needed to give birth. I went to Budi Asih (a local public hospital), and I was told the baby needs oxygen. But I had to wait for the next day. After three days, I lost the baby... [another participant added] After her baby passed away, they put an IUD in her, then she experienced bleeding, and I had to borrow money to pay the hospital bill. (FGD discussion, country: Afghanistan) Women, particularly those from the African region, also faced severe complications from female genital mutilation (FGM)—a practice they experienced in their home countries—including urinary tract infections (UTIs), fistulas, and pregnancy-related complications. These conditions had long-term implications for their menstrual and reproductive health, particularly as some had experienced milestones such as marriage, pregnancy, and childbirth while in transit in Indonesia. The lack of access to specialized healthcare professionals (e.g., gynaecologists) and perceived inadequate health workers’ training in Indonesia, further hindered their ability to receive appropriate medical care and treatment for FGM-related health issues. There is no support and medical assistance, or health access for the refugee women victims who have endured FGM. If their pain or health complication is in the priority list of health cases, there is limited response, and Indonesian doctors have limited knowledge or can’t offer health solutions… There is also a stigma for sharing their pain in the community and those around them… (FGD discussion, country: Somalia) Elderly women diagnosed with chronic conditions such as cardiovascular disease, breast tumours, kidney disease, diabetes, and chronic asthma, reported poor medication compliance due to high OOP expenses and the lack of coverage under humanitarian assistance and programs. As a result, many resorted to purchasing over-the-counter painkillers (e.g., Panadol) from their local general stores, and resorted to alternative medicines such as home-made remedies. Usually, we go to the Puskesmas (local government health clinic) because it’s cheaper and the medicine helps with light health issues like the flu… But for serious complications, they (the Puskesmas) only write a referral letter to specialists and we have to go to a special clinic or hospital, which costs us, and the medical assistance from (humanitarian organization) and all benefits has been cut off. (FGD discussion, country: Sudan ) With the additional costs of transportation to health services, many women either postponed or entirely forwent routine health check-ups (e.g., blood pressure monitoring, glucose testing, and breast screenings). This was particularly prevalent among elderly women, who tended to prioritize their household’s financial security and had poor access to humanitarian assistance. I have a small tumor on my armpit. Many times I went to the hospital, but the doctor said it’s nothing serious, just an infection, but if the lump (tumor) gets bigger, I must have surgery. I couldn’t deal with surgery. The costs are very high, and I’d have to pay by myself. I can’t control regularly to know if it (the tumor) is getting bigger or not and the cost is very high. (FGD discussion, country: Afghanistan) All respondents reportedly experienced psychological distress and poor mental health, with some being diagnosed with anxiety, depression, and suicidal ideation. The contributing factors included financial and economic hardship, uncertain and unstable living and housing arrangements, fear of deportation and inadequate refugee protection, post-traumatic stress disorder (PTSD) from escaping conflict in their home countries, and existing worries from pre-existing health conditions (e.g., physical injuries sustained during their escape, diabetes). However, despite experiencing significant mental health challenges, including those with diagnosed conditions, mental health care was not covered as an essential health condition in the health insurance and benefits provided by the humanitarian assistance programs. As a result, many were unable to access necessary and timely psychological and wellbeing support and treatment, which further exacerbated their psychological stress and distress. Mental health treatment is not available to all refugees and there is long waiting time or receive no health assistant, if you are not a part of the monthly assistant group. If you need more sessions or need to get treatment, the decision is not up to the doctor, but we have to wait for the permission of IOM or UNHCR and partners. (FGD discussion, country: Somalia) Additionally, women who were mothers expressed deep distress about their children’s future and education, and their inability to provide food for them, and concern for family members left behind in their home countries. A participant stated: We waited for a long time in Indonesia. We cannot provide anything for our children. That’s why sometimes we, mothers, go into depression. If our children want anything, we cannot provide, that is very difficult for us. (FGD discussion: country: Yemen) Housing insecurity and living conditions Housing insecurity and poor living conditions emerged as a critical theme, closely linked to financial hardship and adverse health outcomes. The types of accommodation available to transit refugee women varied widely. Some women and their families stayed in temporary shelters provided by IOM, which were free of charge, while others lived in subsidized housing, as well as private rentals that required out-of-pocket expenses. Some respondent women also experienced homelessness. All participants, regardless of their housing or accommodation type, reported substandard living conditions. Overcrowding and shared living arrangements with non-family members, particularly in humanitarian program-provided shelters and subsidized housing, which led to a lack of privacy and frequent conflicts. Additionally, inadequate hygiene and sanitation—such as poor toilet facilities for both men and women, insufficient access to clean drinking water and requiring to buy water, and mouldy roofs and walls—contributed to persistent skin rashes, chronic respiratory issues, spread of infectious diseases, and mental stress and worry. Women and their family members are already suicidal, because of the stress and what we are living under that building and under those conditions… It’s like we are inside one box… There are more than 800 people in the same building (Participant 4, country: Sudan) Additionally, some respondents living in private rentals reported experiencing discriminatory behaviour and harassment from their landlords. They faced frequent rent increases, informal and insecure leasing agreements, and verbal abuse, largely due to their uncertain legal status. This led to fear and psychological distress, driven by housing instability and the constant anxiety of securing private rental accommodation. These concerns were particularly pronounced among women who have family members with disability, and women who were divorced and living in female-headed households. During a group discussion, a participant who was renting and having elderly care, stated: My mother and father are sick. My father is disabled, so if we rent a cheap house, we get one far from the public road and on the 2nd floor. So we had no choice, we rented a house that was easily accessible to the hospital… Once we lived very far away and my father was sick in the middle of the night. At the time, we had no one and no transportation, so my brother carried my father all the way to the hospital - a journey that was over an hour long. Our allowance was cut off too and it’s too expensive for us. (FGD discussion, country: Afghanistan) Physical safety was also a major concern linked to both the living environments and the locations of their accommodation. The majority of respondents reported experiencing various forms of SGBV, including domestic and intimate partner violence by an immediate family member or cohabitants, and sexual harassment by locals (e.g., taxi, bus drivers). These experiences were particularly common among younger women and those in female-headed households. As a coping mechanism, many women and their daughters avoided going outside after certain hours and/or restricted their mobility beyond their accommodation. Girls and women are very scared, and we restrict our movement because of the safety and harassment issues.. It’s psychologically distressing to us… We also know that because of language barriers, we are targets of harassment and at risk of being unsafe… (FGD discussion: country: Somalia) Discussion This study explored the lived experiences of transit refugee women in Indonesia, focusing on how precarious housing and living conditions determine their health outcomes and healthcare access. The findings highlight how their health challenges were deeply rooted in financial hardship, with limited humanitarian assistance and the barriers and instability posed by their housing and living conditions. These challenges affected their access to timely and essential healthcare related to their sexual and reproductive health, chronic diseases management, mental ill health, and experiences of sexual and gender-based violence. Legal exclusion and the consequences for refugee women’s health and wellbeing With Indonesia being a non-member of the 1951 Refugee Convention or its Protocol , refugees have no legal recognition or state protection, and are prohibited from income-generating opportunities and employment, have limited access to public services (mainly education and health), and live in diverse, unstable and precarious housing arrangements—all of which are exacerbating their health inequities and vulnerabilities [ 24 ]. While Indonesia has shifted from detaining refugees in immigration detention centres to alternative accommodation models, these changes present complex and nuanced challenges. Missbach (2015) argues that although this shift may appear to represent ‘progress’, it has in fact resulted in new forms of containment that do not necessarily improve living conditions or access to humanitarian assistance and services. As refugees remain highly dependent on the limited (and increasingly reduced) support provided by humanitarian organizations, mainly UNHCR and IOM, their access to basic needs such as housing, food assistance, clean and drinking water, healthcare and health insurance, and cash assistance, is unevenly distributed [ 25 ]. Similar to our findings, other studies also highlight how housing insecurity, housing model, and poor living conditions, often characterised by overcrowded, unhygienic conditions, and limited privacy, adversely impact health outcomes, including the spread of infectious diseases, poor ventilation and air quality, and poor hygiene and sanitation. Collective living models, sharing with unknown people, and poor physical infrastructure are found to heighten levels of mental ill health, including anxiety and depression, insomnia, social isolation, and difficulties accessing psychosocial support [ 25 ]. For women and children especially, living with aggressive people, unknown people, and in unsafe environments, increased their vulnerabilities and experiences of nightmares, sleeplessness, anxiety, a sense of powerlessness, and risks of sexual violence [ 25 ]. Studies from high-income host countries indicate that poor housing conditions—characterized by overcrowding, instability, and inadequate physical environments—contribute to adverse physical and mental health outcomes among refugee populations [ 26 ]. Despite this knowledge, there remains a lack of understanding of how housing inequalities and precarious living conditions among transit refugees intersect with different housing models and their lived experiences across various transit contexts. Our findings also highlight that limited humanitarian assistance and restricted access to healthcare and financial support significantly impact refugee women's SRHR. In contexts where refugees rely on aid for essential services, gaps in funding, inconsistent service provision, and eligibility restrictions often lead to inadequate access to pregnancy care, menstrual health supplies, and contraceptives. This has led to pregnancy complications, miscarriages, and poor child health outcomes, as well as undermines women’s ability to make informed choices about their reproductive health, plan their families, and manage their menstrual hygiene. Corroborating these findings, Grotti et al. (2018) which examined reproductive women’s health access in three Mediterranean countries (which are common transit routes and entry points into Europe), found that despite these countries providing varying levels of pregnancy-related healthcare and health assistance, they had to seek privately funded healthcare for pregnancy care and childbirth (27). Additionally, limited access to testing, treatment, and health education compromises efforts to prevent and control HIV and other sexually transmitted infections (STIs), which are common among refugee girls and women in transit contexts who face heightened risk of sexual and gender-based violence (SGBV), including rape and sexual exploitation [ 28 ]. Unmarried women are particularly vulnerable to child marriage, while married women face increased risk of intimate partner violence and domestic abuse [ 28 ]. Studies also corroborate our findings, revealing how refugee women originating from the African region, where traditional FGM practices continue, face heightened health risks, including severe pregnancy and childbirth complications, chronic pelvic pain, infections, and menstrual health complications, which are exacerbated by the lack of specialised medical services in transit settings [ 29 ]. Bridging vulnerabilities of transit refugee women in transit contexts While much of the current literature on refugee women’s health in humanitarian contexts focuses on access to services and protection from a human rights perspective, there is limited understanding of how the conditions of transit—particularly their living environments, housing arrangements, and overall physical surroundings—shape their health outcomes and everyday vulnerabilities. This gap is especially evident when examined from the perspective of legalities and subnational budgetary implications of transit across different contexts and particularly from a gendered perspective [ 25 ]. Refugee women, especially throughout the phases of migration, often experience compounded vulnerabilities due to their sex and gender, particularly in the context of weak or absent legal protection. Gender-based violence, sexual exploitation, and coercion remain a pervasive threat - especially in overcrowded shelters, informal housing, or during movement through unfamiliar regions [26, 29 ]. Inadequate access to sexual and reproductive health services further undermines their wellbeing, with limited availability of pregnancy care, menstrual hygiene products, family planning services, and prevention of SGBV [ 31 , 32 ]. Women also carry the disproportionate burden of unpaid care work and child-rearing responsibility in already strained environments, which limit their ability to seek support services, further entrenching their marginalisation. Even in countries that are signatories to the 1951 Refugee Convention —such as Mexico, which functions as both a host and transit destination—refugees are housed in various shelter models and may receive temporary humanitarian visas, conditional work rights, and access to the public health system [ 31 , 32 ]. However, these provisions are not without shortcomings—including an overburdened healthcare system and persistent barriers to accessing services, particularly for women seeking SRH, such as safe abortion, family planning services, and GBV prevention and support [ 31 , 32 ]. In contrast, countries like Bangladesh, not a signatory to the Refugee Convention, have established designated camp settings and community-based housing models for transit refugees, working in partnership with government agencies, NGOs, and various UN agencies. These settings include women and girls' safe spaces, health posts, maternal health centres, and trained community health workers, who deliver culturally tailored services—including family planning, contraceptive uptake, pregnancy care, and psychosocial counselling—specifically targeting women’s health needs. Evaluations from Cox’s Bazar have shown that tailored psychosocial support, skill‑building activities, and protection services significantly enhance women’s health, health outcomes, reduce exposure to or incidence of violence against women and girls, and improve women’s resilience [ 33 ]. Study limitations Our study faced two major limitations. First, our study was limited to transit refugees in Greater Jakarta, restricting insights into refugee experiences elsewhere in Indonesia. Many refugees, particularly Rohingya populations, arrive by boat and are initially sheltered under emergency response in multiple locations such as Banda Aceh, where different socio-cultural and environmental conditions may shape their experiences. Excluding other regions may have limited insights into how socio-cultural dynamics, host community interactions, and local governance shape transit refugees' challenges, coping strategies, and access to health services. Second, all our research participants were members of our research collaborator’s transit refugee network. This may imply that these refugee women have had better access to social support, networks, and healthcare services than those without such affiliations. To address these limitations, future research could expand recruitment to include more isolated refugee women without community support or affiliations, providing a broader understanding of their challenges and access to healthcare and services in transit contexts. New contribution to literature Our findings highlight an underexplored dimension in the literature on refugee health: the need for context-specific, gender-responsive approaches that extend beyond short-term humanitarian responses to uphold dignity, autonomy, and long-term well-being. While previous research has examined the precariousness of refugees’ access to essential services, our study demonstrates that transit refugees—particularly in countries where legal protection is absent and dependence on humanitarian aid is absolute—face distinctive layers of vulnerability that remain insufficiently conceptualized. These vulnerabilities are not limited to gaps in immediate relief but are compounded by the systemic failure to secure basic needs such as safe housing, food security, and financial support. We contribute to emerging debates by proposing that addressing these inequities requires reframing refugee health not solely as a humanitarian concern [ 34 ], but as a matter of rights-based, equity-driven policy embedded within cross-sectoral systems of support. This perspective foregrounds the urgency of inclusion, legal recognition, and sustained access to health services in transit contexts—settings often overlooked in global health and migration scholarship. Importantly, we argue that even in the absence of rapid reform in international legal frameworks, there is space to rethink and innovate pathways for ensuring health access in transit environments, many of which are located in LMICs already managing heavy domestic health burdens. This advances the literature by positioning refugee health access and their access to healthcare, capacity building, and resilience planning. By doing so, it shifts the discourse from reactive, emergency-focused interventions to structural, future-oriented solutions that acknowledge transit as not merely temporary, but as a critical site of health equity policymaking. Declarations Funding This study was funded by Monash University, Indonesia. Author Contribution GF led the conceptualisation and design of the study, coordinated data collection, and led the thematic analysis. GF drafted the initial manuscript and coordinated revisions through to finalisation. SP, AAIDT, and NC coordinated and conducted data collection, contributed to the study conceptualisation and design and to the thematic analysis, provided methodological guidance for the qualitative analysis, and were actively involved in drafting, critically reviewing, and revising the manuscript. NA mediated research partnerships and collaborations, coordinated data collection and fieldwork logistics, and contributed to manuscript revisions. All authors contributed to the interpretation of findings, reviewed and approved the final manuscript, and agree to be accountable for all aspects of the work. Acknowledgement We extend our heartfelt gratitude to Sisterhood for their unwavering collaboration and support throughout this research. Our deepest thanks go to all the sisters who welcomed us into their lives, sharing their stories, experiences, and trust, which made this work meaningful and deeply enriching. We also extend our thanks to Dr Jessica Watterson and Dr Kadek Urwasi for their support in the project’s design and for providing valuable feedback on its deliverables. References UNHCR, Global Trends R. 2024. UNHCR; 2025 Jun 13. Available from: https://www.unhcr.org/global-trends-report-2024 Vukčević Marković M, Bobić A, Živanović M. The effects of traumatic experiences during transit and pushback on the mental health of refugees, asylum seekers, and migrants. Eur J Psychotraumatol. 2023;14(1):2163064. https://doi.org/10.1080/20008066.2022.2163064 . Purić D, Vukčević Marković M. Development and validation of the Stressful Experiences in Transit Questionnaire (SET-Q) and its Short Form (SET-SF). Eur J Psychotraumatol. 2019;10(1):1611091. https://doi.org/10.1080/20008198.2019.1611091 . Düvell F. Transit migration: A blurred and politicised concept. Popul Space Place. 2012;18:415–427. https://doi.org/10.1002/psp.631 Teodorescu, L. (2024). Women on the move. Understanding the female face of migration to develop targeted policies. Eur View. 2024;23(1):55–63. https://doi.org/10.1177/17816858241246662 . Nasar S, Raz S, Parray AA, et al. An assessment of gender vulnerability in the humanitarian crisis in Cox’s Bazar, Bangladesh: Developing a gender-based vulnerability index in the Rohingya and Host community contexts. Int J Disaster Risk Reduct. 2022;81:103246. https://doi.org/10.1016/j.ijdrr.2022.103246 . Sullivan C, Block K, Vaughan C, Isham L, Bradbury-Jones C. The continuum of gender-based violence across the refugee experience. In: Understanding Gender-Based Violence. Springer Int Publishing. 2021;33–47. https://doi.org/10.1007/978-3-030-65006-3_3 . Chalouhi J, Currow DC, Dumit NY, Sawleshwarkar S, Glass N, Stanfield S, Digiacomo M, Davidson PM. The health and well-being of women and girls who are refugees: A case for action. Int J Environ Res Public Health. 2025;22(2):204. https://doi.org/10.3390/ijerph22020204 . Sawadogo PM, Sia D, Onadja Y, Beogo I, Sangli G, Sawadogo N, Gnambani A, Bassinga G, Robins S, Tchouaket Nguemeleu E. Barriers and facilitators of access to sexual and reproductive health services among migrant, internally displaced, asylum seeking and refugee women: A scoping review. PLoS ONE. 2023;18(9):e0291486. https://doi.org/10.1371/journal.pone.0291486 . Fernando G, Khafiyya A, Tricesaria A, et al. Healthcare access and outcomes for refugee women in transit: A scoping review of facilitators and barriers in South and Southeast Asia. J Immigr Minor Health. 2025. https://doi.org/10.1007/s10903-025-01722-wde . Bruijn B. The living conditions and well-being of refugees. IDEAS Working Paper Series from RePEc. 2009. Khan MN, Islam MM, Rahman MM, Rahman MM. Access to female contraceptives by Rohingya refugees, Bangladesh. Bull World Health Organ. 2021;99(3):201–8. https://doi.org/10.2471/BLT.20.269779 . Albayrak H, Cankurtaran Ö, Bahar-Özvarış Ş, Erdost T. They taught us not only our rights as women, but also how to live. Gender-based violence and empowerment experiences of Syrian women in Turkey and the role of women and girls safe spaces: A qualitative study. Health Care Women Int. 2022;43(7–8):946–63. https://doi.org/10.1080/07399332.2021.1975120 . Ali ASMA, Khamees RAA. Living conditions and public health challenges in temporary camps for displaced populations in Shendi Locality, Sudan. J Epidemiol Glob Health. 2025;15(1):64. https://doi.org/10.1007/s44197-025-00405-x . Sukiasyan S. The mental health of refugees and forcibly displaced people: A narrative review. Consort Psychiatr. 2024;5(4):78–92. https://doi.org/10.17816/CP15552 . Missbach A. Asylum seekers’ and refugees’ decision-making in transit in Indonesia. Bijdr Taal Land Volkenkd. 2019;175(4):419–45. https://doi.org/10.1163/22134379-17504006 . Missbach A. Making a career in people-smuggling in Indonesia: Protracted transit, restricted mobility and asylum-seekers’ need for protection. Sojourn. 2015;30(2):423–54. Dewansyah B, Nafisah RD. The Constitutional Right to Asylum and Humanitarianism in Indonesian Law: Foreign Refugees and PR 125/2016. Asian J Law Soc. 2021;8(3):536–57. 10.1017/als.2021.8 . Lau B, Ramadhan S, Yusuf T. A transit country no more: Refugees and asylum seekers in Indonesia. Mixed Migration Centre; 2021 May. Available from: https://mixedmigration.org/wp-content/uploads/2021/05/170_Indonesia_Transit_Country_No_More_Research_Report.pdf Immordino P, Graci D, Casuccio A, Restivo V, Mazzucco W. COVID-19 vaccination in migrants and refugees: Lessons learnt and good practices. Vaccines (Basel). 2022;10(11):1965. https://doi.org/10.3390/vaccines10111965 . Creswell JW, Poth CN. Qualitative inquiry & research design: Choosing among five approaches. 5th ed. Sage; 2025. Arcadi P, Figura M, Simeone S, Pucciarelli G, Vellone E, Alvaro R. The health of a migrant population: A phenomenological study of the experience of refugees and asylum seekers in a multicultural context. Nurs Rep. 2024;14(2):1388–401. https://doi.org/10.3390/nursingreports14020100 . Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa . Tan NF. The status of asylum seekers and refugees in Indonesia. Int J Refugee Law. 2016;28(3):365–83. https://doi.org/10.1093/ijrl/eew045 . Missbach A, Adiputera Y. The Role of Local Governments in Accommodating Refugees in Indonesia: Investigating Best-Case and Worst-Case Scenarios. Asian J Law Soc. 2021;8(3):490–506. 10.1017/als.2021.5 . Spira J, Katsampa D, Wright H, Komolafe K. The relationship between housing and asylum seekers' mental health: A systematic review. Soc Sci Med. 2025;368:117814. https://doi.org/10.1016/j.socscimed.2025.117814 . Rana K, Kent JL, Page A. Housing inequalities and health outcomes among migrant and refugee populations in high-income countries: A mixed-methods systematic review. BMC Public Health. 2025;25(1):22186. https://doi.org/10.1186/s12889-025-22186-5 . Grotti V, Malakasis C, Quagliariello C, et al. Shifting vulnerabilities: Gender and reproductive care on the migrant trail to Europe. Comp Migr Stud. 2018;6:23. https://doi.org/10.1186/s40878-018-0089-z . Roupetz S, Garbern S, Michael S, Bergquist H, Glaesmer H, Bartels SA. Continuum of sexual and gender-based violence risks among Syrian refugee women and girls in Lebanon. BMC Womens Health. 2020;20(1):10. https://doi.org/10.1186/s12905-020-01009-2 . Elnakib S, Metzler J. A scoping review of FGM in humanitarian settings: An overlooked phenomenon with lifelong consequences. Confl Health. 2022;16(1):48. https://doi.org/10.1186/s13031-022-00479-5 . Davidson N, Hammarberg K, Romero L, et al. Access to preventive sexual and reproductive health care for women from refugee-like backgrounds: A systematic review. BMC Public Health. 2022;22:403. https://doi.org/10.1186/s12889-022-12576-4 . Hawkins MM, Schmitt ME, Adebayo CT, Weitzel J, Olukotun O, Christensen AM, Ruiz AM, Gilman K, Quigley K, Dressel A, Mkandawire-Valhmu L. Promoting the health of refugee women: A scoping literature review incorporating the social ecological model. Int J Equity Health. 2021;20(1):45. https://doi.org/10.1186/s12939-021-01387-5 . Stark L, Robinson MV, Seff I, Gillespie A, Colarelli J, Landis D. The effectiveness of women and girls safe spaces: A systematic review of evidence to address violence against women and girls in humanitarian contexts. Trauma Violence Abuse. 2022;23(4):1249–61. https://doi.org/10.1177/1524838021991306 . Sadjad MS. What Are Refugees Represented to Be? A Frame Analysis of the Presidential Regulation 125 of 2016 Concerning the Treatment of Refugees from Abroad. Asian J Law Soc. 2021;8(3):451–66. 10.1017/als.2021.3 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers invited by journal 04 Mar, 2026 Editor assigned by journal 03 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8728761","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602003024,"identity":"95d32b2d-c497-46ed-91ce-f80a53d5b67c","order_by":0,"name":"Gabriela Fernando","email":"data:image/png;base64,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","orcid":"","institution":"Monash University, Indonesia","correspondingAuthor":true,"prefix":"","firstName":"Gabriela","middleName":"","lastName":"Fernando","suffix":""},{"id":602003025,"identity":"5bf789c9-b5a4-4413-a126-1e6f346e5562","order_by":1,"name":"Anak Agung Istri Diah Tricesaria","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Anak","middleName":"Agung Istri Diah","lastName":"Tricesaria","suffix":""},{"id":602003027,"identity":"9ea5ac30-805a-401f-bf9d-b9c70b4a5f2a","order_by":2,"name":"Nimo Ahmed","email":"","orcid":"","institution":"The Sisterhood","correspondingAuthor":false,"prefix":"","firstName":"Nimo","middleName":"","lastName":"Ahmed","suffix":""},{"id":602003035,"identity":"9dda2fb6-d507-4d5b-a1e5-7ed24bb55798","order_by":3,"name":"Nadira Reza Chairani","email":"","orcid":"","institution":"Monash University, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Nadira","middleName":"Reza","lastName":"Chairani","suffix":""},{"id":602003036,"identity":"7d8ea778-fa2b-462a-a6df-8919e9b4b641","order_by":4,"name":"Sabina Satriyani Puspita","email":"","orcid":"","institution":"Monash University, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Sabina","middleName":"Satriyani","lastName":"Puspita","suffix":""}],"badges":[],"createdAt":"2026-01-29 08:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8728761/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8728761/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104404958,"identity":"1653b80f-1db1-4f43-aa73-a40f8b08bda1","added_by":"auto","created_at":"2026-03-11 12:21:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":714791,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8728761/v1/0f577404-d946-405f-9fec-0f17f709bbe8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Navigating Uncertainty: Exploring the links between Precarious Living Conditions and Health outcomes of Transit Refugee Women in Indonesia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eForced displacement has reached unprecedented levels, with over 117\u0026nbsp;million individuals forcibly displaced due to conflict, famine, human rights violations, persecution, and environmental crises [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among them, transit refugees constitute a significant but often overlooked subcategory. Transit refugees are individuals who have fled their countries and lacking legal protection, including those without asylum seeker status, a valid refugee visa, or whose documentation has expired and/or awaiting sponsorship. They remain in a state of temporary or legal limbo in transit locations while seeking safety and stability in host countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Yet, the absence of a universally accepted definition for transit refugees complicates both academic discourse and policy responses, leaving many in prolonged uncertainty [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWomen represent a majority of the global refugee population, yet their specific experiences and vulnerabilities remain underexplored [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Across the migration journey\u0026mdash;from leaving their home countries to travelling through transit locations and resettling in host countries \u0026mdash;displacement exacerbates existing gender inequalities [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This exposure heightens their risk of sexual and gender-based violence (SGBV), economic marginalization, and restricted access to healthcare and legal protection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite these challenges, migration policies fail to incorporate a gender-responsive approach, further marginalizing transit refugee women within refugee and resettlement contexts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. And, understanding these gendered dimensions of displacement, particularly from a health perspective, requires a broader examination of the social determinants of health that shape refugees' wellbeing, particularly in transit situations.\u003c/p\u003e\n\u003ch3\u003eSocial determinants of transit refugee women\u003c/h3\u003e\n\u003cp\u003eFor refugee women, the social determinants are shaped by displacement, legal status, and transit countries\u0026rsquo; immigration policies, which highlight significant socioeconomic inequities, poverty, inadequate living conditions, and consequential poor health outcomes and inequity in healthcare delivery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The financial constraints, legal restrictions, stigmatization, and language barriers they face when accessing healthcare and services, contribute to their poor physical and surging mental ill health [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The neglect of sexual and reproductive health and rights (SRHR) for transit refugee women has profound consequences, including poor family planning, limited access to contraceptives, inadequate abortion care, insufficient maternal and child birthing care, and weak prevention and control of HIV and sexually transmitted infections (STIs) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This neglect has contributed to high rates of miscarriages, stillbirths, unintended pregnancies, and the spread of STIs and HIV, alongside the high prevalence of SGBV, particularly among girls and women within these contexts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese health needs and healthcare disparities are also linked to the living environments and housing models made available to refugees, which vary based on national policies and the countries\u0026rsquo; signatory status to the \u003cem\u003e1951 Refugee Convention\u003c/em\u003e and its \u003cem\u003e1967 Protocol\u003c/em\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Camp-based models are where refugees typically live in designated, enclosed sites administered by humanitarian agencies or host governments. These settings may offer structured services, including primary health care with components of sexual and reproductive health (i.e., the minimum initial service package), water, and sanitation, through coordinated aid, but can also impose restrictions on their mobility, privacy and economic autonomy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. By contrast, community-based living arrangements allow refugees to live among local host populations, offering independence, mobility, and social integration, yet with limited or fragmented access to formal protection and services such as healthcare [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These varying housing models and precarious living conditions negatively impact women\u0026rsquo;s health outcomes and their access to essential healthcare and treatment in distinct ways. Overcrowding, inadequate housing, poor sanitation, and lack of clean water, increase the risk and spread of infectious diseases, with high food insecurity leading to malnutrition, and chronic disease mismanagement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Mental health, including depression, anxiety, and post-traumatic stress disorder (PTSD), alongside the elevated risk of sexual violence, risk of suicide, is also found to be higher among migrants and refugees in transit, compared to the host populations of these contexts [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRefugees in transit in Indonesia\u003c/h2\u003e \u003cp\u003eSoutheast Asia is a critical transit region for refugees traveling from Africa, the Middle East, and South Asia. Countries such as Malaysia, Indonesia, and Thailand serve as key transit points in the region [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, these nations vary in their legal frameworks and policies toward refugees, often influenced by their non-signatory status to the \u003cem\u003e1951 Refugee Convention\u003c/em\u003e and its \u003cem\u003e1967 Protocol\u003c/em\u003e. Indonesia, which is not a signatory to the Convention, does not provide formal legal recognition or protection for refugees. As a result, most transit refugees, who often come from Afghanistan, Myanmar (Rohingya), Somalia, Iraq, Sudan, and Sri Lanka, remain in prolonged uncertainty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith limited national asylum laws [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], refugee status in Indonesia is determined by the United Nations High Commissioner for Refugees (UNHCR), which grants recognition but does not provide pathways to permanent resettlement within the country [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Due to their lack of legal status, refugees are legally not permitted to work, can only access public schools where there is availability, and are not financially supported to access public health services in Indonesia [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This legal limbo forces many to rely on limited international aid, informal and sex work, and community support for survival [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Indonesian government permits refugees to reside in different models of accommodations, such as community housing funded by humanitarian organizations such as the UNHCR and the International Organization for Migration (IOM), or self-funded private housing [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, livelihood resources are often inadequate, with poor living conditions, persisting health challenges, and long waiting periods for resettlement, sometimes lasting over a decade [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Transit refugee women in Southeast Asia experience significant health challenges, particularly in sexual and reproductive health and mental well-being, shaped by structural barriers such as limited healthcare access, financial hardship due to constrained humanitarian aid, and sociocultural stigma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These challenges were further compounded during the COVID-19 pandemic, with many urban refugees, stateless persons and asylum seekers, often being excluded from vaccination programs, routine screenings, and access to basic healthcare. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven this context and with the growing number of refugees currently living in transit and entering Indonesia, it is crucial to understand how their living conditions impact their health outcomes. While existing research highlights the legal and humanitarian challenges refugees face in precarious living conditions, less is known about how these precarious housing and lived experiences determine their health outcomes, particularly for women within Indonesia\u0026rsquo;s legal and policy framework. Therefore, this study explored the lived experiences of transit refugee women in Indonesia, focusing on how housing and living conditions shape their health outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a participatory qualitative research design to explore the lived experiences of transit refugee women in Indonesia. A phenomenological approach was used to gain in-depth insights into their social determinants of health, particularly how their housing and accommodation arrangements, and living conditions shaped their health outcomes, access to healthcare, and health experiences in Indonesia\u0026rsquo;s transit context [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The participatory approach enabled collaboration with a refugee women\u0026rsquo;s community centre, which co-designed the study\u0026rsquo;s objectives and outcomes, co-created the data collection tools, contributed to data collection\u0026mdash;including recruitment\u0026mdash;and facilitated the dissemination of outputs. Additionally, the community centre provided a safe space for data collection.\u003c/p\u003e\n\u003ch3\u003eParticipant recruitment and sampling\u003c/h3\u003e\n\u003cp\u003e Through our research collaboration, the community centre facilitated recruitment of study participants, who were selected using purposive sampling, followed by snowball sampling. This approach enabled the inclusion of participants with diverse backgrounds, including varying migration histories, lengths of transit in Indonesia, access to healthcare services, and health experiences. To be eligible, participants had to be refugee women currently residing under transit status in the Greater Jakarta area in Indonesia, aged 18 years or older, and willing to provide informed consent (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A total of 27 participants took part in the study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfghanistan: 37%\u003c/p\u003e \u003cp\u003eSomalia: 30%\u003c/p\u003e \u003cp\u003eYemen: 7%\u003c/p\u003e \u003cp\u003eSudan: 7%\u003c/p\u003e \u003cp\u003eSri Lanka: 4%\u003c/p\u003e \u003cp\u003ePakistan: 4%\u003c/p\u003e \u003cp\u003eEgypt: 4%\u003c/p\u003e \u003cp\u003ePalestine: 4%\u003c/p\u003e \u003cp\u003eEritrea: 4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNative language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArabic\u003c/p\u003e \u003cp\u003eYemeni\u003c/p\u003e \u003cp\u003eSinhalese\u003c/p\u003e \u003cp\u003eFarsi\u003c/p\u003e \u003cp\u003eSomali\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;21: 0\u003c/p\u003e \u003cp\u003e21\u0026ndash;35 : 85%\u003c/p\u003e \u003cp\u003e36\u0026ndash;50 : 11%\u003c/p\u003e \u003cp\u003e51\u0026ndash;65 : 4%\u003c/p\u003e \u003cp\u003e65+ : 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo education: 7%\u003c/p\u003e \u003cp\u003ePrimary education only: 15%\u003c/p\u003e \u003cp\u003eSecondary education only: 48%\u003c/p\u003e \u003cp\u003eTertiary education: 30%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle and living alone: 19%\u003c/p\u003e \u003cp\u003eSingle and living with parents/ in a family unit: 22%\u003c/p\u003e \u003cp\u003eSingle and living with friend(s): 4%\u003c/p\u003e \u003cp\u003eMarried and living with family: 56%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo children: 52%\u003c/p\u003e \u003cp\u003e1 child: 15%\u003c/p\u003e \u003cp\u003e2 children: 22%\u003c/p\u003e \u003cp\u003e3\u0026thinsp;+\u0026thinsp;children: 11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousing/ accommodation model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIOM-provided shelter: 30%\u003c/p\u003e \u003cp\u003ePrivate rental: 67%\u003c/p\u003e \u003cp\u003eWithout shelter/ homeless: 4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of transit in Indonesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;2 years: 7%\u003c/p\u003e \u003cp\u003e3\u0026ndash;5 years: 15%\u003c/p\u003e \u003cp\u003e6\u0026ndash;8 years: 44%\u003c/p\u003e \u003cp\u003e9\u0026ndash;11 years: 30%\u003c/p\u003e \u003cp\u003e12\u0026thinsp;+\u0026thinsp;years: 4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistered with UNHCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: 100%\u003c/p\u003e \u003cp\u003eNo: -\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceiving cash assistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: 30%\u003c/p\u003e \u003cp\u003eNo: 70%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData collection methods\u003c/h3\u003e\n\u003cp\u003eData were collected using two qualitative tools: focus group discussions (FGDs) and in-depth semi-structured interviews. FGDs provided insight into shared experiences, collective challenges, and coping strategies among refugees. A total of four FGDs were conducted, each consisting of 4\u0026ndash;5 participants, categorized according to country of origin and region (i.e., Middle Eastern, African, South Asia), and preferred language (Arabic, Farsi, Somali). In addition to the FGDs, one-on-one in-depth interviews were conducted to gain deeper insights into personal experiences that may not have emerged during the FGDs. A total of 8 in-depth interviews were carried out with selected FGD participants and newly recruited participants. Both the in-depth interviews and the FGDs used the same semi-structured discussion guide, which helped to facilitate conversations on several key themes: living conditions and housing arrangements, health status and access to healthcare, food security, mental health, and interactions with humanitarian organizations in Indonesia. Probing questions were used to gather further insights. All FGDs and in-depth interviews were held in the community centre, which provided a neutral and safe location, with interpreters available to ensure effective communication in participants\u0026rsquo; preferred languages.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e s for the study were obtained from the Monash University Human Research Ethics Committee (MUHREC) and in-country approvals from the National Research and Innovation Agency of Indonesia (BRIN). All participants provided informed consent before participation. Confidentiality and anonymity were strictly maintained, with identifying details removed from transcripts and pseudonyms assigned. Given the sensitive nature of the discussions, participants were provided with information about free, affordable mental health support services located in Jakarta, Indonesia, as needed.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003e Some of the FGDs and interviews were audio-recorded with participants\u0026rsquo; consent and transcribed verbatim to English. However, some of the participants refused for their interviews to be audio-recorded, but agreed to have their information recorded by note-takers. All recordings and notes were translated and transcribed verbatim into English. Following Braun and Clarke (2006), thematic analysis was conducted with manual coding and the identification of the themes emerging from the data [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A data analysis and validation of findings were workshopped with selected study participants, and our research collaborators - members from the community centre. This helped to develop the coding framework, which was used to analyse the data. All transcripts were independently coded by two researchers to enhance inter-coder reliability. Any discrepancies were resolved through discussion to ensure consistency and validity in the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity and researcher positionality\u003c/h2\u003e \u003cp\u003eWe acknowledge that none of the researchers have lived experience of forced migration or being transit refugees. Therefore, adopting a participatory approach\u0026mdash;through collaboration with Indonesia\u0026rsquo;s only women-led refugee community organisation\u0026mdash;was essential. This included co-designing the study design, data collection protocols and tools, and the dissemination of findings (including co-authorship of research outputs). Reflexivity was maintained through researcher's journals, documenting biases and assumptions that could influence the study. To increase the credibility and rigour of this work, we workshopped the preliminary findings with a group of transit refugee participants, including the founding members of the women-led refugee organization. This member-checking process ensured that our interpretations accurately reflected participants' lived experiences, fostered collaborative knowledge production, and strengthened the study\u0026rsquo;s methodological integrity.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe findings of this study highlight the multiple and intersecting challenges that transit refugee women face in accessing healthcare, securing adequate accommodation, and managing their living conditions. A central theme that emerged was the restricted access to healthcare, which was closely linked to the type of humanitarian support they received, which determined their access to timely medicine/ treatment and specialist services. The analysis also revealed that housing and accommodation models played a significant role in shaping their living conditions, which further negatively influenced and exacerbated their physical and mental health outcomes. Intersectional factors such as women's age, family structure, country of origin, and native language played a crucial role in shaping their healthcare experiences. These factors influenced access to healthcare due to language barriers, experiences of violence and discrimination by healthcare professionals, which contributed to the worsening of health issues while living in transit.\u003c/p\u003e\n\u003ch3\u003ePersisting health challenges and financial hardship\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eA common theme that was discussed was women’s sexual and reproductive health and rights, and a majority of the women reported that they experienced significant issues related to their menstrual health and hygiene. Due to financial hardship, many were forced to use a single sanitary pad for an entire day during their menstrual cycle, increasing the risk of infections and discomfort. Limited access to free and proper menstrual hygiene products and inadequate sanitation facilities further exacerbated these issues.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMenstrual health problems are common among us women, and there’s high rates of infection and UTIs, and infection risks due to extended use of sanitary pads… Sometimes, they’d use just one sanitary napkin for an entire day, as refugee women can't afford enough supplies… Since UNHCR and partners stopped the support for supplies last year, this situation is worse for us… \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion, country: Somalia)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, while some reproductive-aged women had access to family planning and contraceptives (e.g., IUDs), they lacked adequate health information and understanding about these methods, and in some cases, contraceptives were inserted without their full knowledge, particularly post-pregnancy or miscarriage. Many women also experienced pregnancy complications and miscarriages due to the lack of adequate ante- and post-natal care. High out-of-pocket (OOP) expenses, coupled with limited financial coverage provided by humanitarian assistance programs, limited their access to essential maternal health services. Under the current healthcare provisions, women were only able to access reproductive health services at the time of childbirth, as delivery was categorized as an emergency condition. However, routine antenatal care, which is crucial for preventing pregnancy-related complications and ensuring maternal and child health, remained largely inaccessible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e…I needed to give birth. I went to Budi Asih (a local public hospital), and I was told the baby needs oxygen. But I had to wait for the next day. After three days, I lost the baby... [another participant added] After her baby passed away, they put an IUD in her, then she experienced bleeding, and I had to borrow money to pay the hospital bill.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;(FGD discussion, country: Afghanistan)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWomen, particularly those from the African region, also faced severe complications from female genital mutilation (FGM)—a practice they experienced in their home countries—including urinary tract infections (UTIs), fistulas, and pregnancy-related complications. These conditions had long-term implications for their menstrual and reproductive health, particularly as some had experienced milestones such as marriage, pregnancy, and childbirth while in transit in Indonesia. The lack of access to specialized healthcare professionals (e.g., gynaecologists) and perceived inadequate health workers’ training in Indonesia, further hindered their ability to receive appropriate medical care and treatment for FGM-related health issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere is no support and medical assistance, or health access for the refugee women victims who have endured FGM. If their pain or health complication is in the priority list of health cases, there is limited response, and Indonesian doctors have limited knowledge or can’t offer health solutions… There is also a stigma for sharing their pain in the community and those around them…\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion, country: Somalia)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eElderly women diagnosed with chronic conditions such as cardiovascular disease, breast tumours, kidney disease, diabetes, and chronic asthma, reported poor medication compliance due to high OOP expenses and the lack of coverage under humanitarian assistance and programs. As a result, many resorted to purchasing over-the-counter painkillers (e.g., Panadol) from their local general stores, and resorted to alternative medicines such as home-made remedies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUsually, we go to the Puskesmas (local government health clinic) because it’s cheaper and the medicine helps with light health issues like the flu… But for serious complications, they (the Puskesmas) only write a referral letter to specialists and we have to go to a special clinic or hospital, which costs us, and the medical assistance from (humanitarian organization) and all benefits has been cut off.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion, country: Sudan )\u0026nbsp;\u003cbr\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWith the additional costs of transportation to health services, many women either postponed or entirely forwent routine health check-ups (e.g., blood pressure monitoring, glucose testing, and breast screenings). This was particularly prevalent among elderly women, who tended to prioritize their household’s financial security and had poor access to humanitarian assistance. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI have a small tumor on my armpit. Many times I went to the hospital, but the doctor said it’s nothing serious, just an infection, but if the lump (tumor) gets bigger, I must have surgery. I couldn’t deal with surgery. The costs are very high, and I’d have to pay by myself. I can’t control regularly to know if it (the tumor) is getting bigger or not and the cost is very high.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;(FGD discussion, country: Afghanistan)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll respondents reportedly experienced psychological distress and poor mental health, with some being diagnosed with anxiety, depression, and suicidal ideation. The contributing factors included financial and economic hardship, uncertain and unstable living and housing arrangements, fear of deportation and inadequate refugee protection, post-traumatic stress disorder (PTSD) from escaping conflict in their home countries, and existing worries from pre-existing health conditions (e.g., physical injuries sustained during their escape, diabetes). However, despite experiencing significant mental health challenges, including those with diagnosed conditions, mental health care was not covered as an essential health condition in the health insurance and benefits provided by the humanitarian assistance programs. As a result, many were unable to access necessary and timely psychological and wellbeing support and treatment, which further exacerbated their psychological stress and distress.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMental health treatment is not available to all refugees and there is long waiting time or receive no health assistant, if you are not a part of the monthly assistant group. If you need more sessions or need to get treatment, the decision is not up to the doctor, but we have to wait for the permission of IOM or UNHCR and partners.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion, country: Somalia)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, women who were mothers expressed deep distress about their children’s future and education, and their inability to provide food for them, and concern for family members left behind in their home countries. A participant stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe waited for a long time in Indonesia. We cannot provide anything for our children. That’s why sometimes we, mothers, go into depression. If our children want anything, we cannot provide, that is very difficult for us.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion: country: Yemen)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eHousing insecurity and living conditions \u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eHousing insecurity and poor living conditions emerged as a critical theme, closely linked to financial hardship and adverse health outcomes. The types of accommodation available to transit refugee women varied widely. Some women and their families stayed in temporary shelters provided by IOM, which were free of charge, while others lived in subsidized housing, as well as private rentals that required out-of-pocket expenses. Some respondent women also experienced homelessness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants, regardless of their housing or accommodation type, reported substandard living conditions. Overcrowding and shared living arrangements with non-family members, particularly in humanitarian program-provided shelters and subsidized housing, which led to a lack of privacy and frequent conflicts. Additionally, inadequate hygiene and sanitation—such as poor toilet facilities for both men and women, insufficient access to clean drinking water and requiring to buy water, and mouldy roofs and walls—contributed to persistent skin rashes, chronic respiratory issues, spread of infectious diseases, and mental stress and worry.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWomen and their family members are already suicidal, because of the stress and what we are living under that building and under those conditions… It’s like we are inside one box… There are more than 800 people in the same building\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(Participant 4, country: Sudan)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, some respondents living in private rentals reported experiencing discriminatory behaviour and harassment from their landlords. They faced frequent rent increases, informal and insecure leasing agreements, and verbal abuse, largely due to their uncertain legal status. This led to fear and psychological distress, driven by housing instability and the constant anxiety of securing private rental accommodation. These concerns were particularly pronounced among women who have family members with disability, and women who were divorced and living in female-headed households. During a group discussion, a participant who was renting and having elderly care, stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMy mother and father are sick. My father is disabled, so if we rent a cheap house, we get one far from the public road and on the 2nd floor. So we had no choice, we rented a house that was easily accessible to the hospital… Once we lived very far away and my father was sick in the middle of the night. At the time, we had no one and no transportation, so my brother carried my father all the way to the hospital - a journey that was over an hour long. Our allowance was cut off too and it’s too expensive for us.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion, country: Afghanistan)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePhysical safety was also a major concern linked to both the living environments and the locations of their accommodation. The majority of respondents reported experiencing various forms of SGBV, including domestic and intimate partner violence by an immediate family member or cohabitants, and sexual harassment by locals (e.g., taxi, bus drivers). These experiences were particularly common among younger women and those in female-headed households. As a coping mechanism, many women and their daughters avoided going outside after certain hours and/or restricted their mobility beyond their accommodation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGirls and women are very scared, and we restrict our movement because of the safety and harassment issues.. It’s psychologically distressing to us… We also know that because of language barriers, \u0026nbsp;we are targets of harassment and at risk of being unsafe…\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(FGD discussion: country: Somalia)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the lived experiences of transit refugee women in Indonesia, focusing on how precarious housing and living conditions determine their health outcomes and healthcare access. The findings highlight how their health challenges were deeply rooted in financial hardship, with limited humanitarian assistance and the barriers and instability posed by their housing and living conditions. These challenges affected their access to timely and essential healthcare related to their sexual and reproductive health, chronic diseases management, mental ill health, and experiences of sexual and gender-based violence.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eLegal exclusion and the consequences for refugee women\u0026rsquo;s health and wellbeing\u003c/h2\u003e \u003cp\u003eWith Indonesia being a non-member of the \u003cem\u003e1951 Refugee Convention\u003c/em\u003e or \u003cem\u003eits Protocol\u003c/em\u003e, refugees have no legal recognition or state protection, and are prohibited from income-generating opportunities and employment, have limited access to public services (mainly education and health), and live in diverse, unstable and precarious housing arrangements\u0026mdash;all of which are exacerbating their health inequities and vulnerabilities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. While Indonesia has shifted from detaining refugees in immigration detention centres to alternative accommodation models, these changes present complex and nuanced challenges. Missbach (2015) argues that although this shift may appear to represent \u0026lsquo;progress\u0026rsquo;, it has in fact resulted in new forms of containment that do not necessarily improve living conditions or access to humanitarian assistance and services. As refugees remain highly dependent on the limited (and increasingly reduced) support provided by humanitarian organizations, mainly UNHCR and IOM, their access to basic needs such as housing, food assistance, clean and drinking water, healthcare and health insurance, and cash assistance, is unevenly distributed [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilar to our findings, other studies also highlight how housing insecurity, housing model, and poor living conditions, often characterised by overcrowded, unhygienic conditions, and limited privacy, adversely impact health outcomes, including the spread of infectious diseases, poor ventilation and air quality, and poor hygiene and sanitation. Collective living models, sharing with unknown people, and poor physical infrastructure are found to heighten levels of mental ill health, including anxiety and depression, insomnia, social isolation, and difficulties accessing psychosocial support [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. For women and children especially, living with aggressive people, unknown people, and in unsafe environments, increased their vulnerabilities and experiences of nightmares, sleeplessness, anxiety, a sense of powerlessness, and risks of sexual violence [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies from high-income host countries indicate that poor housing conditions\u0026mdash;characterized by overcrowding, instability, and inadequate physical environments\u0026mdash;contribute to adverse physical and mental health outcomes among refugee populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Despite this knowledge, there remains a lack of understanding of how housing inequalities and precarious living conditions among transit refugees intersect with different housing models and their lived experiences across various transit contexts.\u003c/p\u003e \u003cp\u003eOur findings also highlight that limited humanitarian assistance and restricted access to healthcare and financial support significantly impact refugee women's SRHR. In contexts where refugees rely on aid for essential services, gaps in funding, inconsistent service provision, and eligibility restrictions often lead to inadequate access to pregnancy care, menstrual health supplies, and contraceptives. This has led to pregnancy complications, miscarriages, and poor child health outcomes, as well as undermines women\u0026rsquo;s ability to make informed choices about their reproductive health, plan their families, and manage their menstrual hygiene. Corroborating these findings, Grotti et al. (2018) which examined reproductive women\u0026rsquo;s health access in three Mediterranean countries (which are common transit routes and entry points into Europe), found that despite these countries providing varying levels of pregnancy-related healthcare and health assistance, they had to seek privately funded healthcare for pregnancy care and childbirth (27).\u003c/p\u003e \u003cp\u003eAdditionally, limited access to testing, treatment, and health education compromises efforts to prevent and control HIV and other sexually transmitted infections (STIs), which are common among refugee girls and women in transit contexts who face heightened risk of sexual and gender-based violence (SGBV), including rape and sexual exploitation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Unmarried women are particularly vulnerable to child marriage, while married women face increased risk of intimate partner violence and domestic abuse [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Studies also corroborate our findings, revealing how refugee women originating from the African region, where traditional FGM practices continue, face heightened health risks, including severe pregnancy and childbirth complications, chronic pelvic pain, infections, and menstrual health complications, which are exacerbated by the lack of specialised medical services in transit settings [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eBridging vulnerabilities of transit refugee women in transit contexts\u003c/h2\u003e \u003cp\u003eWhile much of the current literature on refugee women\u0026rsquo;s health in humanitarian contexts focuses on access to services and protection from a human rights perspective, there is limited understanding of how the conditions of transit\u0026mdash;particularly their living environments, housing arrangements, and overall physical surroundings\u0026mdash;shape their health outcomes and everyday vulnerabilities. This gap is especially evident when examined from the perspective of legalities and subnational budgetary implications of transit across different contexts and particularly from a gendered perspective [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Refugee women, especially throughout the phases of migration, often experience compounded vulnerabilities due to their sex and gender, particularly in the context of weak or absent legal protection. Gender-based violence, sexual exploitation, and coercion remain a pervasive threat - especially in overcrowded shelters, informal housing, or during movement through unfamiliar regions [26, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Inadequate access to sexual and reproductive health services further undermines their wellbeing, with limited availability of pregnancy care, menstrual hygiene products, family planning services, and prevention of SGBV [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Women also carry the disproportionate burden of unpaid care work and child-rearing responsibility in already strained environments, which limit their ability to seek support services, further entrenching their marginalisation.\u003c/p\u003e \u003cp\u003eEven in countries that are signatories to the \u003cem\u003e1951 Refugee Convention\u003c/em\u003e\u0026mdash;such as Mexico, which functions as both a host and transit destination\u0026mdash;refugees are housed in various shelter models and may receive temporary humanitarian visas, conditional work rights, and access to the public health system [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, these provisions are not without shortcomings\u0026mdash;including an overburdened healthcare system and persistent barriers to accessing services, particularly for women seeking SRH, such as safe abortion, family planning services, and GBV prevention and support [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In contrast, countries like Bangladesh, not a signatory to the Refugee Convention, have established designated camp settings and community-based housing models for transit refugees, working in partnership with government agencies, NGOs, and various UN agencies. These settings include women and girls' safe spaces, health posts, maternal health centres, and trained community health workers, who deliver culturally tailored services\u0026mdash;including family planning, contraceptive uptake, pregnancy care, and psychosocial counselling\u0026mdash;specifically targeting women\u0026rsquo;s health needs. Evaluations from Cox\u0026rsquo;s Bazar have shown that tailored psychosocial support, skill‑building activities, and protection services significantly enhance women\u0026rsquo;s health, health outcomes, reduce exposure to or incidence of violence against women and girls, and improve women\u0026rsquo;s resilience [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eOur study faced two major limitations. First, our study was limited to transit refugees in Greater Jakarta, restricting insights into refugee experiences elsewhere in Indonesia. Many refugees, particularly Rohingya populations, arrive by boat and are initially sheltered under emergency response in multiple locations such as Banda Aceh, where different socio-cultural and environmental conditions may shape their experiences. Excluding other regions may have limited insights into how socio-cultural dynamics, host community interactions, and local governance shape transit refugees' challenges, coping strategies, and access to health services. Second, all our research participants were members of our research collaborator\u0026rsquo;s transit refugee network. This may imply that these refugee women have had better access to social support, networks, and healthcare services than those without such affiliations. To address these limitations, future research could expand recruitment to include more isolated refugee women without community support or affiliations, providing a broader understanding of their challenges and access to healthcare and services in transit contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eNew contribution to literature\u003c/h2\u003e \u003cp\u003eOur findings highlight an underexplored dimension in the literature on refugee health: the need for context-specific, gender-responsive approaches that extend beyond short-term humanitarian responses to uphold dignity, autonomy, and long-term well-being. While previous research has examined the precariousness of refugees\u0026rsquo; access to essential services, our study demonstrates that transit refugees\u0026mdash;particularly in countries where legal protection is absent and dependence on humanitarian aid is absolute\u0026mdash;face distinctive layers of vulnerability that remain insufficiently conceptualized. These vulnerabilities are not limited to gaps in immediate relief but are compounded by the systemic failure to secure basic needs such as safe housing, food security, and financial support.\u003c/p\u003e \u003cp\u003eWe contribute to emerging debates by proposing that addressing these inequities requires reframing refugee health not solely as a humanitarian concern [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], but as a matter of rights-based, equity-driven policy embedded within cross-sectoral systems of support. This perspective foregrounds the urgency of inclusion, legal recognition, and sustained access to health services in transit contexts\u0026mdash;settings often overlooked in global health and migration scholarship. Importantly, we argue that even in the absence of rapid reform in international legal frameworks, there is space to rethink and innovate pathways for ensuring health access in transit environments, many of which are located in LMICs already managing heavy domestic health burdens. This advances the literature by positioning refugee health access and their access to healthcare, capacity building, and resilience planning. By doing so, it shifts the discourse from reactive, emergency-focused interventions to structural, future-oriented solutions that acknowledge transit as not merely temporary, but as a critical site of health equity policymaking.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was funded by Monash University, Indonesia.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGF led the conceptualisation and design of the study, coordinated data collection, and led the thematic analysis. GF drafted the initial manuscript and coordinated revisions through to finalisation. SP, AAIDT, and NC coordinated and conducted data collection, contributed to the study conceptualisation and design and to the thematic analysis, provided methodological guidance for the qualitative analysis, and were actively involved in drafting, critically reviewing, and revising the manuscript. NA mediated research partnerships and collaborations, coordinated data collection and fieldwork logistics, and contributed to manuscript revisions. All authors contributed to the interpretation of findings, reviewed and approved the final manuscript, and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe extend our heartfelt gratitude to Sisterhood for their unwavering collaboration and support throughout this research. Our deepest thanks go to all the sisters who welcomed us into their lives, sharing their stories, experiences, and trust, which made this work meaningful and deeply enriching. We also extend our thanks to Dr Jessica Watterson and Dr Kadek Urwasi for their support in the project\u0026rsquo;s design and for providing valuable feedback on its deliverables.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNHCR, Global Trends R. 2024. UNHCR; 2025 Jun 13. 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Asian J Law Soc. 2021;8(3):451\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/als.2021.3\u003c/span\u003e\u003cspan address=\"10.1017/als.2021.3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Transit refugee women, sexual and reproductive health, gender-based violence, precarious living conditions, health equity","lastPublishedDoi":"10.21203/rs.3.rs-8728761/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8728761/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWith humanitarian crises intensifying globally, Indonesia\u0026mdash;situated within Southeast Asia\u0026mdash;has increasingly become a critical transit hub along major migratory routes for refugees and asylum seekers. Among those in transit, women face distinct vulnerabilities shaped by gendered risks, limited access to legal protection, and barriers to essential services, making their living conditions and health outcomes particularly precarious. Using a participatory phenomenological approach, this study explored the lived experiences of refugee women in transit in Indonesia, focusing on how their precarious housing and living conditions shaped their health outcomes. The research consisted of four focus group discussions and eight in-depth interviews, involving women from Afghanistan, Somalia, Sudan, Sri Lanka, Yemen, Pakistan, Egypt, Palestine, and Eritrea. The study was conducted in collaboration with a community organisation led by and for refugee women in transit in Indonesia. Findings revealed that women\u0026rsquo;s precarious living conditions and health outcomes were closely tied to the access and availability of support services, including having registered humanitarian cards that provided varying levels of healthcare, food assistance, cash aid, and housing support. However, not all participants were registered, and eligibility criteria for registration to receive humanitarian support differed, resulting in unequal affordability and access to essential healthcare\u0026mdash;particularly sexual and reproductive health services such as pregnancy care, menstrual health, family planning and contraceptives, mental health support, and management of chronic diseases like tumours and diabetes. These disparities often led to delayed or foregone medical check-ups, including tumour screenings, trauma counselling, and antenatal care. Some women experienced pregnancy complications, miscarriages, or postpartum health issues, with heightened risks for those who had undergone female genital mutilation before their transit journey. Housing conditions\u0026mdash;whether supported by humanitarian assistance, reliant on private rental, or marked by homelessness\u0026mdash;further shaped their health outcomes. Overcrowded living arrangements increased disease transmission, while inadequate water and sanitation, exposure to sexual and gender-based violence, and persistent mental distress, compounded their vulnerabilities. The study informs the need for greater efforts to implement gender-responsive policies and health programs that ensure refugee women\u0026rsquo;s safety and equitable and comprehensive access to health and housing support, particularly in precarious transit conditions.\u003c/p\u003e","manuscriptTitle":"Navigating Uncertainty: Exploring the links between Precarious Living Conditions and Health outcomes of Transit Refugee Women in Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 18:39:50","doi":"10.21203/rs.3.rs-8728761/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-16T18:02:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27196797541926786609612986637854864691","date":"2026-03-10T16:02:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-04T15:51:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T05:55:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T05:53:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2026-01-29T07:35:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b0b4c963-d0f0-4cb8-822c-fc5f15a1a11d","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T18:39:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 18:39:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8728761","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8728761","identity":"rs-8728761","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}