Gender and caste inequalities in primary healthcare usage by under-5 children in rural Nepal:an iterative qualitative study into provider perspectives and the potential role of implicit bias


OBJECTIVE: This study explored provider perspectives on: (1) why inequalities in health service usage persist; and (2) their knowledge and understanding of the role of patient experience and implicit bias (also referred to as unconscious bias). DESIGN: A three stage, iterative qualitative study was conducted involving two rounds of in-depth interviews and a training session with healthcare staff. Interview transcripts were analysed using a reflexive thematic approach in relation to the study's aims. SETTING: Participants were recruited from rural hill districts (Mugu, Humla, Bajura, Gorkha and Sindhupalchok) of Nepal. PARTICIPANTS: Clinical staff from 22 rural health posts. RESULTS: Healthcare providers had high levels of understanding of the cultural, educational and socioeconomic factors behind inequalities in healthcare usage in their communities. However, there was less knowledge and understanding of the role of patient experience-and no recognition at all of the concept of implicit bias. CONCLUSION: It is highly likely that implicit bias affects provider behaviours in Nepal, just as it does in other countries. However, there is currently not a culture of thinking about the patient experience and how that might impact on future usage of health services. Implicit bias training for health students and workers would help create greater awareness of unintended discriminatory behaviours. This in turn may play a part in improving patient experience and future healthcare usage, particularly among disadvantaged groups.

Publication DOI:
Divisions: College of Health & Life Sciences > School of Optometry > Optometry
College of Health & Life Sciences
Additional Information: Copyright © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: Funding Information: This research was supported by the UK Economic and Social Research Council’s GCRF NGO Secondary Data Analysis Initiative, Grant Ref: ES/T010436/1.
Uncontrolled Keywords: Humans,Child,Bias, Implicit,Nepal,Social Class,Qualitative Research,Primary Health Care
Publication ISSN: 2044-6055
Last Modified: 06 Dec 2023 12:31
Date Deposited: 17 Jul 2023 11:39
Full Text Link: 10.1136/bmjopen-2022-069060
Related URLs: https://bmjopen ... nt/13/6/e069060 (Publisher URL)
PURE Output Type: Article
Published Date: 2023-06-26
Published Online Date: 2023-06-26
Accepted Date: 2023-06-12
Authors: Joshi, Saugat
Karki, Alisha
Rushton, Simon
Koirala, Bikash
Basnet, Srijana
Rijal, Barsha
Karki, Jiban
Pohl, Gerda
Baidya, Manish
Chater, Tim
Green, Dan (ORCID Profile 0000-0003-1934-6725)
Lee, Andrew



Version: Published Version

License: Creative Commons Attribution

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