Indian Institute of Public Health Bhubaneswar, Bhubaneswar, India.
Health System Transformation Platform, New Delhi, India.
Int J Equity Health. 2023 Jan 5;22(1):2. doi: 10.1186/s12939-022-01817-y.
Reaching hard to reach populations is key to reduce health inequities. Despite targeted interventions, status of crucial public health indicators like neonatal and maternal mortality is still far from optimal. Complex interplay of social determinants can influence both communities and health care workers to effectively access each other. We argue that culturally sensitive and contextually relevant healthcare provision has potential to increase health care utilization by the vulnerable communities living in remote areas.
The study is an exploratory case study using rapid ethnographic techniques to understand the interplay of social determinants in hard to reach areas of Odisha state, India. We used in-depth interviews, focus group discussion, participatory action research and key informant interviews as tools for data collection. The analysis of data has been guided by thematic analysis approach.
We found that there are further layers within the designated hard to reach areas and those can be designated as-i) extremely remote ii) remote and iii) reachable areas. Degree of geographic difficulties and cultural dynamics are deciding the 'perceived' isolation and interaction with health care providers in hard to reach areas. This ultimately leads to impacting the utilization of the facilities. At extremely remote areas, felt health needs are mainly fulfilled by traditional healers and ethno-medical practices. In reachable areas, people are more prone to seek care from the public health facilities because of easy accessibility and outreach. Being in middle people in remote areas, diversify health care seeking depending upon social (e.g. patient's gender) economic (e.g. avoid catastrophic expenditure) and health system (timely availability of health human resources, language barriers) factors.
Our research highlights the need to value and appreciate different worldviews, beliefs and practices, and their understanding of and engagement with the pluralistic health care system around them. Other than pursuing the 'mainstreaming' of a standardized health system model across hard to reach areas, strategies need to be adaptive as per local factors. To handle that existing policies need revision with a focus on culturally sensitive and contextual care provision.
缩小健康差距的关键是接触到难以接触到的人群。尽管采取了有针对性的干预措施，但新生儿和产妇死亡率等关键公共卫生指标的状况仍远不理想。社会决定因素的复杂相互作用会影响社区和卫生保健工作者彼此有效地接触。我们认为，具有文化敏感性和与背景相关的医疗保健提供有可能增加生活在偏远地区的弱势社区对医疗保健的利用。
这项研究是一项探索性案例研究，采用快速民族志技术来了解印度奥里萨邦难以到达地区社会决定因素的相互作用。我们使用深入访谈、焦点小组讨论、参与式行动研究和关键知情人访谈作为数据收集工具。数据分析遵循主题分析方法。
我们发现，在指定的难以到达地区内还有进一步的层次，可以将其指定为- i）极偏远地区、ii）偏远地区和 iii）可达地区。地理困难和文化动态的程度决定了在难以到达地区与医疗保健提供者的“感知”隔离和互动，这最终影响了设施的利用。在极偏远地区，传统的治疗师和民族医学实践主要满足了人们的健康需求。在可达地区，由于易于获得和外展，人们更倾向于从公共卫生设施寻求医疗服务。在偏远地区的人们则根据社会（例如患者的性别）、经济（例如避免灾难性支出）和卫生系统（卫生人力资源的及时可用性、语言障碍）因素，多样化寻求医疗服务。
我们的研究强调了需要重视和欣赏不同的世界观、信仰和实践，以及他们对多元化医疗保健系统的理解和参与。除了在难以到达的地区推行主流标准化卫生系统模式之外，还需要根据当地因素制定适应性策略。为了应对这一挑战，需要对现有政策进行修订，重点关注文化敏感性和背景相关的护理提供。
