Exploring Health and Wellbeing in a Low-to-Middle Income Country: A Case Study of Kenya

Abstract

The recent past has witnessed an increased interest in the concept of wellbeing both in academia and public policy. Governments and international organizations have developed a policy agenda with the broad goal of improving individual and collective wellbeing; positioning it as the desired outcome of, and the benchmark with which to evaluate social and economic progress, and the effectiveness of governments and their policies. The majority of such efforts have been conducted in Euro-American nations with limited efforts in developing countries. In the low-to-middle income countries where such efforts exist, they are based on experiences and indicators from the high-income western countries. As such, limited initiatives that aim to understand how wellbeing is conceptualized in time and place exist in low-to-middle income countries (LMICs) as societal progress in these resource-constrained areas are persistently assessed by econometric measures such as Gross Domestic Product (GDP). To address this gap, the present thesis explored indicators for constructing a healthy population index, an important domain of societal wellbeing in the context of LMICs. As part of the global index of wellbeing project, this thesis set out to understand how Kenyans socially construct their health and wellbeing across place, socio-demographic characteristics, and over their life-course. Using an explorative study design, the thesis employs the social constructionists’ perspectives and the eco-social theory to answer three specific research questions. First, the thesis responds to the question, what are the perceptions, meanings and determinants of societal health and wellbeing that matter most to Kenyans and are there differences and similarities by gender and region? Second, how do the youth (15-24 years), the middle-aged (25-49) and the seniors (≥50 years) in Kenya socially construct their health and wellbeing? Third and lastly, what are the indicators of a healthy population domain of wellbeing that matter in the context of Kenya and are there potential secondary data sets that could be used to evaluate progress in health over the past years and into the future? In answering these questions, this thesis adopted qualitative research methodologies – including in-depth interviews (IDIs) and focus group discussions (FGDs). The IDIs with representatives of youth groups (male and female), women, and men groups, representatives of Community-Based Organizations (CBO), and with policy makers (i.e., Member of County Assembly) were conducted to explore their work and lived experiences of health and wellbeing in their respective communities. Focus group discussions (FGDs) with lay participants were conducted to understand their perceptions, meanings, determinants and the social construction of societal health and wellbeing and to determine similarities and differences by gender and across place. The thesis also highlights the indicators of the healthy population domain that matter to Kenyans as revealed in the collected data and suggest potential data sources for evaluating progress. Using the constructs of embodiment and pathways of embodiment of the eco-social theory, the thesis provides a framework with which to map population health indicators for wellbeing assessment in the context of LMICs. The social constructionists’ viewpoint on the other hand, is employed in this thesis to explore the social production of knowledge about societal health and wellbeing. The findings reveal that concepts of healthy community and a good life (a proxy of wellbeing) are used interchangeably and are defined using similar concepts. Additionally, having a healthy community and a good life is shown to be dependent on the ability of the community to meet the basic needs for all its members. Specifically, six themes emerge as critical descriptors of a healthy community and a good life in Kenya: a) community health status and quality of healthcare; b) economic and living standard factors; c) social relationships; d) the state of the environment; e) political and governance issues; and f) cultural and societal values, beliefs, norms and practices which influence perceptions and meanings of population health and wellbeing. These contextual factors and the individual and immediate factors interact to create social hierarchies based on gender, age, social class, and regional power imbalances which limit accessibility to resources to certain groups of people. For example, the findings show that gender-based violence (GBV) is a key social determinant of health which disproportionally affects women because of the preexisting cultural structures that act to disempower them. Moreover, the findings reveal that the politics and governance structures – including real engagement in political decision-making, tribalism, corruption and electoral violence are important factors that propagate health inequalities in communities, thus influencing perceptions and meanings of health and wellbeing. Furthermore, the results of this thesis reveal that across their life-course, Kenyans adopt unique social constructs to explain their lived experiences of health and wellbeing. The youth (15-24 years) for example, consider themselves as – “bleeding bodies”, “untrustworthy bodies”, “culturally disadvantaged bodies” and “bodies at risk”. The middle-aged (25-49 years), on the other hand, construct health and wellbeing around issues of domestic violence, whereas the seniors (≥50 years) narrate how they embody distress associated with care for their children and grandchildren in contexts characterized by economic poverty and socio-cultural erosion. According to the participants’ narratives, the indicators for the healthy population domain range from health outcome indicators such as the prevalence and incidence rates for infectious diseases (e.g. HIV and the opportunistic diseases), non-communicable diseases (e.g. cancer, hypertension, diabetes and unintentional injuries), mortality rates as well as accessibility, effectiveness and acceptability of healthcare services, lifestyle and behavior, and indicators of public health programs. Theoretically, this study provides the wellbeing literature with a rudimentary framework premised on the social constructionists’ perspectives and the eco-social theory for understanding the healthy population indicators that matter in LMICs. In so doing, it highlights socially, geographically and culturally relevant indicators thus allowing for evidence-based policy and policy evaluation across time and space. For example, this research reveals that even though constructs around community health status and quality of healthcare services remain frequent descriptors of the health and wellbeing of populations, social and cultural inclusion, issues such as GBV, socio-cultural erosion and care responsibilities are some aspects of the community that need to be included in evaluation of progress in health and quality of life. This information is important in formulation of relevant health policies and interventions.