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Gautron JMC, Tu Thanh G, Barasa V, Voltolina G. Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries. Health Policy Plan 2023; 38:1017-1032. [PMID: 37599460 PMCID: PMC10566319 DOI: 10.1093/heapol/czad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/29/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023] Open
Abstract
Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.
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Affiliation(s)
- Juliette M C Gautron
- Department of Social Anthropology, University of Cambridge, Free School Lane, Cambridge, CB2 3RF, United Kingdom
| | - Giada Tu Thanh
- Independent Consultant, Gran de Gracia, Barcelona 08012, Spain
| | - Violet Barasa
- Institute of Development Studies, University of Sussex, Library Road, Brighton & Hove, BN1 9RE, United Kingdom
| | - Giovanna Voltolina
- Itad, Preece House, Davigdor Road, Brighton & Hove, BN3 1RE, United Kingdom
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Musoke D, Raven J, Basnet S, Idriss A, Phiri B, Ssemugabo C, Tsey IH, Ozano K. Using photovoice to inform and support health systems to reach marginalised populations: experiences from six low- and middle-income countries. Glob Public Health 2022; 17:3912-3930. [PMID: 35770692 DOI: 10.1080/17441692.2022.2092179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Photovoice methodology centralises the voices of marginalised populations within health systems using photography and critical dialogue to record, reflect and communicate community health issues. This paper presents findings from applying photovoice to explore and document the lived experiences of groups of marginalised populations in six low- and middle-income countries: Cambodia, Ghana, Nepal, Sierra Leone, Uganda and Zambia. The strengths of using photovoice included: creating safe spaces for communication; community solidarity and stakeholder engagement; community ownership of actions and advocacy; developing new soft skills and confidence; capturing hidden community challenges; and taking collective action. Suggestions for use in future photovoice studies include: providing space for the exploration of contextual factors before implementation; developing a capacity strengthening plan to ensure participants have the competencies required to effectively take part in research and dissemination; considering the use of non-visual methods alongside photovoice when needed; and having in place partnership structures between researchers and participants that facilitate power sharing, agency, empowerment and joint decision making. Lastly, we present recommendations that have the potential to strengthen the value and use of photovoice as more than a participatory method but also a vehicle for individual, relational and health systems improvements.
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Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sapana Basnet
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Ayesha Idriss
- Department of Pharmacology, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Bevis Phiri
- Clinton Health Access Initiative - HIV Programme (Research), Lusaka, Zambia
| | - Charles Ssemugabo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Honam Tsey
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Ghana
| | - Kim Ozano
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Oviedo-Cáceres MDP, Arias-Valencia S, Hernández-Quirama A, Ruiz-Rodríguez M, Guisasola-Valencia L. Intersectionality and access to visual rehabilitation services: Experiences of people with low vision, a qualitative study. BRITISH JOURNAL OF VISUAL IMPAIRMENT 2022. [DOI: 10.1177/02646196221104902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low vision is a condition of visual impairment, generated by an underlying pathology that affects visual functioning and the development of daily activities. In the field of visual impairment, the developments in the analysis of access to rehabilitation services are scarce and incipient. The study approaches the understanding of the experiences of people with low vision in Medellín, Colombia, in their search for visual rehabilitation services. Ethnographic collective case study was conducted. Intersectionality was adopted to explore people’s experiences with low vision management health services. Five women and four men with low vision who attended the healthcare center participated in the study. Twenty-nine interviews and 16 participant observation exercises were carried out. Three categories emerged in the study: (1) I had never heard of low vision services; (2) Interaction with the health system: A path of struggles; and (3) Barriers that are exacerbated by the intersection of multiple identities and systems of oppression. The Colombian health system acts as an axis of structural oppression that interacts with the economic condition, educational level, and geographical location to generate greater difficulties for the identification of low vision management options, which also interact with the multiple and dynamic identities of each subject.
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Siller H, Aydin N. Using an Intersectional Lens on Vulnerability and Resilience in Minority and/or Marginalized Groups During the COVID-19 Pandemic: A Narrative Review. Front Psychol 2022; 13:894103. [PMID: 35664166 PMCID: PMC9158486 DOI: 10.3389/fpsyg.2022.894103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
Throughout the pandemic, the media and scholars have widely discussed increasing social inequality and thereby publicly pointed to often hidden and neglected forms of inequality. However, the "newly" arisen awareness has not yet been put into action to reduce this inequality. Dealing with social inequality implies exploring and confronting social privileges, which are often seen as the other side of inequality. These social constructs, inequality and privilege, are often discussed in light of vulnerability and resilience. This is particularly important in the context of the worldwide coronavirus disease 2019 (COVID-19) pandemic and efforts to end the pandemic, as both constructs are discussed regarding access to healthcare, vaccination, and education and knowledge, misinformation, social resources, economic resources, and so forth. Minority and/or marginalized groups may be particularly vulnerable to the impact of the COVID-19 pandemic. However, resilience factors in these groups may be neglected and underreported. This narrative review aims at illustrating the specific and intertwined aspects of resilience and vulnerability in minority and/or marginalized groups during the COVID-19 pandemic. To achieve this, we use an intersectional lens based on recommendations made by Moradi and Grzanka. A total of 48 articles were included in the narrative review. Most of them were commentaries focusing on social inequality, vulnerability, and/or resilience. Based on the dissection of articles at structural, systemic, and individual levels, we propose three hypothesis on vulnerability and resilience in minority and marginalized individuals and groups: (1) social inequality must be considered at a global level; inequality at a global level translates into a vulnerable context for an individual; (2) vulnerability is historically situated: vulnerability (experienced during the pandemic) is maintained and reinforced by history; (3) strength through collective (historical) hardship: vulnerability is not the opposite of resilience but may serve as an aspect of resilience. The conclusions drawn from this review show that we need to include diverse voices to advance concepts, such as vulnerability and resilience, in minority and marginalized groups. Additionally, these concepts are not necessarily in opposition to each other, but vulnerability should be understood as an integral part of resilience.
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Affiliation(s)
- Heidi Siller
- Department for Psychology, University of Klagenfurt, Klagenfurt, Austria
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Lee-Foon NK, Logie CH, Siddiqi A, Grace D. Exploring young Black gay, bisexual and other men who have sex with men's PrEP knowledge in Toronto, Ontario, Canada. CULTURE, HEALTH & SEXUALITY 2022; 24:301-314. [PMID: 33196378 DOI: 10.1080/13691058.2020.1837958] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 10/13/2020] [Indexed: 06/11/2023]
Abstract
Despite significant advances in the HIV treatment and prevention landscape such as pre-exposure prophylaxis (PrEP), young Black-Canadian gay, bisexual and other sexual minority men continue to experience disproportionately high rates of HIV infection. While research has explored the factors associated with their higher HIV exposure and the efficacy of STI/HIV prevention programmes, there remains a paucity of research on their knowledge of HIV prevention strategies such as PrEP. We interviewed twenty-two young men and used a constructivist grounded theory approach to qualitatively analyse these young men's PrEP knowledge. Intersectionality and the social ecological model allowed us to explore how social locations (e.g. race, sexual orientation), interacted with individual, interpersonal and community contexts to shape their understanding. Our analysis revealed two interrelated barriers to PrEP knowledge and uptake. The first centred on the ineffectiveness of institutions in disseminating PrEP information to participants. The second focused on the impact of participants' social locations and perceptions of PrEP users based on their PrEP knowledge. Findings suggest the need for more targeted, culturally congruent PrEP dissemination strategies and PrEP prescription policies that acknowledge the various social locations and ecologies in which young Black gay, bisexual and other men who have sex with men reside.
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Affiliation(s)
- Nakia K Lee-Foon
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, Factor Inwentash School of Social Work University of Toronto, Toronto, Ontario, Canada
| | - Arjumand Siddiqi
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Daniel Grace
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
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Barasa V, Virhia J. Using Intersectionality to Identify Gendered Barriers to Health-Seeking for Febrile Illness in Agro-Pastoralist Settings in Tanzania. Front Glob Womens Health 2022; 2:746402. [PMID: 35156085 PMCID: PMC8835114 DOI: 10.3389/fgwh.2021.746402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/17/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundResearch has shown that gender is a significant determinant of health-seeking behavior around the world. Gender power relations and lay etiologies of illness can influence the distribution of household resources, including for healthcare. In some rural settings in Africa, gender intersects with multiple forms of health inequities, from proximal socio-cultural factors to more “upstream” or distal health system determinants which can amplify barriers to health-seeking for specific groups in specific contexts.AimWe used an intersectionality approach to determine how women in particular, experience gendered barriers to accessing healthcare among Maa and non-Maa speaking agro-pastoralists in northern Tanzania. We also explored lay etiologies of febrile illness, perceptions of health providers and rural health-seeking behavior in order to identify the most common barriers to accessing healthcare in these settings.MethodsMixed method ethnographic approaches were used to collect data between 2016 and 2018 from four Maa-speaking and two Swahili-speaking agro-pastoralist villages in northern Tanzania. Maa-speaking villages were based in Naiti, Monduli district while non-Maa speaking villages were selected from Msitu in Babati district. Data on health seeking behaviors was collected through semi-structured questionnaires, in-depth interviews, focus group discussions, and home and facility-based participant observation.FindingsThe results primarily focus on the qualitative outcomes of both studies. We found that febrile illness was locally categorized across a spectrum of severity ranging from normal and expected illness to serious illness that required hospital treatment. Remedial actions taken to treat febrile illness included attending local health facilities, obtaining medicines from drug sellers and use of herbal remedies. We found barriers to health-seeking played out at different scales, from the health system, community (inter-household decision making) and household (intra-household decision making). Gender-based barriers at the household had a profound effect on health-seeking. Younger married women delayed seeking healthcare the most, as they often had to negotiate health-seeking with husbands and extended family members, including co-wives and mothers-in-law who make the majority of health-related decisions.ConclusionAn intersectional approach enabled us to gain a nuanced understanding of determinants of health-seeking behavior beyond the commonly assumed barriers such lack of public health infrastructure. We propose tapping into the potential of senior older women involved in local therapy-management groups, to explore gender-transformative approaches to health-seeking, including tackling gender-based barriers at the community level. While these social factors are important, ultimately, improving the public health infrastructure in these settings is a first step toward addressing structural determinants of treatment-seeking.
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Affiliation(s)
- Violet Barasa
- The Institute of Development Studies, University of Sussex, Brighton, United Kingdom
- *Correspondence: Violet Barasa
| | - Jennika Virhia
- The Institute of Health and Wellbeing, School of Social and Political Science, The University of Glasgow, Glasgow, United Kingdom
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Embracing challenging complexity: exploring handwashing behavior from a combined socioecological and intersectional perspective in Sierra Leone. BMC Public Health 2021; 21:1857. [PMID: 34649535 PMCID: PMC8515313 DOI: 10.1186/s12889-021-11923-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior. Methods This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data. Results The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions. Conclusion This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital). Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11923-1.
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Shibli H, Aharonson-Daniel L, Feder-Bubis P. Perceptions about the accessibility of healthcare services among ethnic minority women: a qualitative study among Arab Bedouins in Israel. Int J Equity Health 2021; 20:117. [PMID: 33964946 PMCID: PMC8106134 DOI: 10.1186/s12939-021-01464-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/29/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Access to healthcare services has major implications for vulnerable populations' health. Socio-cultural and gender characteristics shape the utilization and access of healthcare services among ethnic minorities worldwide. One such vulnerable ethnic minority is the Arab Bedouin women in Israel. As women, they are marginalized in their community, where women do not have full equity and they experience multiple barriers to healthcare services The main objective of this study is to provide a nuanced, experiential, emic description of healthcare accessibility issues among Bedouin women in Israel. Identifying the barriers, they face in accessing healthcare may help healthcare policymakers make changes based on and tailored to Bedouin women's needs. METHODS A qualitative study included in-depth semi-structured interviews with 21 Arab Bedouin village residents, consisting of 14 women and 7 men. Eligible participants were Arab Bedouins over 18 years of age and who used healthcare services at least once in the last 5 years. The interviews were carried out in Arabic-Bedouin dialect and included demographic questions, open-ended questions that asked about participants' perceptions regarding their experiences with healthcare services, including the factors that helped and hindered them in accessing these services and questions regarding suggestions for improving the accessibility of healthcare services based on the identified needs. Data collected were analyzed using thematic analysis. Study trustworthiness was ensured using audit, reflexivity, and peer debriefing. RESULTS Arab Bedouin women experienced varied barriers while accessing healthcare services. This study uncovered how language, cultural and gender barriers intersect with other disadvantages ingrained in social norms, values and beliefs and affect the access of a minority women subgroup to healthcare services. The participants identified subgroups of Bedouin women (e.g. elderly Bedouin women) affected differently by these barriers. CONCLUSION Taking into consideration the identified needs and the Arab Bedouin women's unique characteristics, along with adopting the intersectional approach should help improve access to healthcare services among such a vulnerable subgroup and other subgroups within minorities worldwide.
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Affiliation(s)
- Haneen Shibli
- School of Public Health, Faculty of Health Sciences, Faculty of Health Sciences, PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Limor Aharonson-Daniel
- School of Public Health, Faculty of Health Sciences, Faculty of Health Sciences, PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Paula Feder-Bubis
- School of Public Health, Faculty of Health Sciences, Faculty of Health Sciences, PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Systems Management, Faculty of Health Sciences & Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Campbell KA, MacKinnon K, Dobbins M, Jack SM. Nurse-Family Partnership and Geography: An Intersectional Perspective. Glob Qual Nurs Res 2020; 7:2333393619900888. [PMID: 32010739 PMCID: PMC6974751 DOI: 10.1177/2333393619900888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 11/15/2022] Open
Abstract
Nurse-Family Partnership is a targeted public health intervention program designed to improve child and maternal health through nurse home visiting. In the context of a process evaluation, we posed the question: "In what ways do Canadian public health nurses explain their experiences with delivering this program across different geographical environments?" The qualitative methodology of interpretive description guided study decisions and data were collected through 10 focus groups with 50 nurses conducted over 2 years. We applied an intersectionality lens to explore the influence of all types of geography on the delivery of Nurse-Family Partnership. The findings from our analysis suggest that the nature of clients' place and their associated social and physical geography emphasizes inadequacies of organizational and support structures that create health inequities for clients. Geography had a significant impact on program delivery for clients who were living with multiple forms of oppression and it worked to reinforce disadvantage.
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Affiliation(s)
- Karen A. Campbell
- McMaster University, Hamilton, Ontario,
Canada
- Karen A. Campbell, 91 Oakside Dr., Uxbridge, ON,
Canada L9P 2A7.
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McCollum R, Taegtmeyer M, Otiso L, Mireku M, Muturi N, Martineau T, Theobald S. Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya. Int J Equity Health 2019; 18:65. [PMID: 31064355 PMCID: PMC6505258 DOI: 10.1186/s12939-019-0967-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/22/2019] [Indexed: 01/17/2023] Open
Abstract
Background Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi’s equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. Methods We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Results Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. Conclusions If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | | | | | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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