|Year : 2018 | Volume
| Issue : 1 | Page : 43-47
Understanding the fundamental elements of global health: Using the sen capability approach as the theoretical framework for a health needs assessment in deprived communities
Lilian Ndomoto1, Arthur Hibble2, Gladys Obuzor3, Nthula Nthusi3, Anna Quine3, Prit Chahal3, Sammy O Barasa4, Njeri Nyanja5, Charlotte Tulinius6
1 Department of HIV care and treatment, Nazareth Hospital, Nairobi, Kenya
2 Hughes Hall, Cambridge University, Cambridge, UK
3 Department of General Practice Postgraduate Education, NHS Health Education England, East of, England
4 Department of Nursing, Kenya Medical Training College, Chuka, Kenya
5 AIC Kijabe Hospital, Kijabe; Department of Family Medicine, Kabarak University, Nakuru, Kenya
6 Research Unit and Department of General Practice, Copenhagen University, Copenhagen, Denmark
|Date of Web Publication||14-Aug-2018|
Visiting Professor Primary Care, Anglia Ruskin University, Tutor, Hughes Hall, Cambridge University, 1 Searle Street, Cambridge, CB4 3DB
Source of Support: None, Conflict of Interest: None
Background: The health needs in poor communities are often dictated by data that is not relevant to the community. The capabilities approach (CA) offers a philosophical and practical way to frame and analyse data and apply it to a community using the World Health Organisation socioeconomic framework. This was part of the NHS Health Education England East Midlands Global Health Exchange Fellow Programme. Methods: A team of 2 Kenyan and 2 UK community clinicians worked together in deprived communities in Kenya and the UK using qualitative research methods to facilitate the communities to define and prioritise their health needs and to explore their potential resources and how they might achieve their needs sustainably. The CA was used in the data collection and data analysis phases. Results: The team of fellows gained personal understanding of the reality of the impact of social determinants on health experiences and outcomes. The CA offers the health systems and services a way to engage hard to reach communities with issues that they know to be important and are then able to prioritise. Clinicians who are taught in the evidence based style need to reframe their understanding of community needs if they are to be effective in their work. Working in this way can challenge their own values and beliefs. With planned support this can be a powerful developmental process and the CA is a set of principles that can be used to facilitate the empowerment of communities, the service planners and providers.
Keywords: Capability approach, deprivation, experiential learning, global health, global health exchange fellowship, health needs analysis, socioeconomic determinants of health
|How to cite this article:|
Ndomoto L, Hibble A, Obuzor G, Nthusi N, Quine A, Chahal P, Barasa SO, Nyanja N, Tulinius C. Understanding the fundamental elements of global health: Using the sen capability approach as the theoretical framework for a health needs assessment in deprived communities. Educ Health 2018;31:43-7
|How to cite this URL:|
Ndomoto L, Hibble A, Obuzor G, Nthusi N, Quine A, Chahal P, Barasa SO, Nyanja N, Tulinius C. Understanding the fundamental elements of global health: Using the sen capability approach as the theoretical framework for a health needs assessment in deprived communities. Educ Health [serial online] 2018 [cited 2021 May 19];31:43-7. Available from: https://www.educationforhealth.net/text.asp?2018/31/1/43/239046
| Background|| |
The World Health Organisation defines health as complete physical, mental and social well-being not just the absence of disease or infirmity. Being healthy enables one to function and inequalities in health are inequalities in a person's capability to function. To understand the mechanisms of inequity, health must incorporate the social determinants of health.
As part of a Global Health Exchange Fellowship Programme a group of 4 fellows undertook a health needs assessment, in poor and socially deprived areas; one in a rural community in Kenya and the other in an urban area in the UK. Allowing four health professionals experiential learning in two different, but both highly deprived communities, the aim was to help the population of the two communities to understand their health needs and develop sustainable solutions within their existing resources. As a theoretical frame of analysis we used the global health definition of the Consortium of Universities for Global Health, which highlights how it differs from public and international health and highlights the socioeconomic determinants of health.
“The capabilities approach (CA) states that freedom to achieve well-being is a matter of what people are able to do and to be, and thus the kind of life they are effectively able to lead.” A person's capability to live a good life is defined in terms of the set of 'beings and doings' like being in good health or having loving relationships, to which they have real access [Figure 1].
According to Amartya Sen , people and their communities generally desire to live in better health and know what they need to do so. They have resources but may not be able to utilise them. The degree to which a person can transform a resource into a functioning is a conversion factor. If a resource is present in a community and a conversion factor is lacking then the resource will not be a functioning. A person may have access to a bicycle (resource) but until they learn (conversation factor) to ride it (functioning), it is not a mode of transport or a source of income generation (utility).
Nussbaum, extended the approach with ten central human capabilities: Life, bodily health, sense imagination and thought, emotions, practical reason, affiliation, play, control over one's environment, (political and material) and relating to other species  that might or might not coincide with the needs or wants of the community.
A health needs assessment identifies unmet health and healthcare needs and the changes needed to meet these unmet needs. They are often externally driven, designed with the best of intentions, and determined according to predetermined assumptions, data sets and analysed according to best practice as defined in different contexts and cultures. The CA respects and values the beliefs of the community and data is collected without preconceived understanding. This should lead to better engagement and sustainability. The capacity to benefit might be greater than available resources and should incorporate priority setting.
In this paper we describe a practical application of CA in a community prioritised health needs analyses in socially deprived areas to gain new insights into global health issues in two different parts of the world; a socially deprived rural Kenyan community and an urban deprived UK community.
| Methods|| |
The work of the study took place in the Kenyan rural community in October–December 2015, and in the UK urban community between January and March 2016. We applied CA for data collection and analysis as well as the interpretation of the results.
Using CA at data collection level we undertook key informant interviews, focus groups  and participant observation , These methods were chosen to focus on conceptual understanding, inter-relationship between culture, traditions, beliefs and perceptions of health. The methods were used in both communities to collect data on groups' and individuals' perceptions of health and how it might be improved.
Capabilities approach as the theoretical frame for data collection and analysis
The identified health needs were analysed through a thematic analysis  categorising the data into prioritised health needs (themes) among the interviewees in both the Kenyan and the UK communities. After the themes had been identified we developed a method to allow the community to validate and prioritise them.
We also identified the resources within the community through the key informant interviews, review of published information, participant-observations, and clarifying the potential use of the available resources. Further meetings were held in the communities to discuss and clarify the findings. Achieving better health (functionings), was discussed in relation to ways to achieve this (conversion factors), what was needed to get to better health (resources), and the potential consequences for the individuals as well as the populations (utilities).
Capabilities approach as theoretical frame of reference for the interpretation of the analysis
CA was applied as the theoretical frame of reference for a conceptual interpretation of the results in this paper. This has allowed new insight into the two different contexts of prioritised needs and support for locally sourced potential solutions.
| Results|| |
Capabilities approach applied to the data collection and analysis.
In total we undertook 55 key informant interviews, 600 h of participant observation; we used our 1600 pages of notes as text data and 750 photographs.
By collecting data with the expectation that people need not only resources, but also conversion factors to give the resource a utility, we gained insights into the individual's as well as the populations' health perceptions, beliefs, and the social and cultural contexts. Ten themes of health issues emerged for the Kenyan community, and 12 themes in the UK. Common themes were described across the two communities, including access to health, poverty, sanitation and hygiene, infectious diseases, youth, nutrition, culture and gender inequality [Figure 2].
|Figure 2: The similarities and differences in the health issues prioritised as the most important health needs in the two studied communities|
Click here to view
The two communities discussed and prioritised the themes, made choices and prioritized themes according to their perceived importance and contribution to their wellbeing. The CA of this study was reinforced by the discussion of potential solutions, using locally available resources.
Capabilities approach applied to the conceptual interpretation of global health issues
To illustrate the application of Sen's CA at a conceptual level we have focused on the issue of “health care access,” and interpreted it according to the descriptors of resources, conversion factors, functionings, and utilities. The complexity is illustrated by the fact that elements of the other health issue themes interact with each of the themes, playing different roles as functionings, conversion factors, resources and utilities for the theme of “access to health.” Therefore, we describe not just the theme of “access to health,” but its interaction with elements of poverty, health and sanitation and education.
Capabilities approach applied to conceptually understand the global health need of “access to health”
In the Kenyan community the health facilities are 1 h drive away. There are two hospitals that offer 24 h care at all levels, two hours' drive from the village. The few, who could, travelled by walking, a donkey, a motor bike or rarely by private car. The long distance, cost and limited options affected the capability of the poor, the very sick, women in labour, the frail and elderly, to access and make use of the resource of the health facilities. Whilst health care is free at the point of delivery they didn't have the conversion factors to access it.
In the UK community there are local healthcare centres and GP surgeries, and most of the community live <15 min to the nearest facility and with the opportunity to use a public transport system if necessary. Being a multiethnic population with high turnover and less than half of them being native English speakers the barriers were not about transport to the facilities. Their barriers were how to access the health care system, how to understand the healthcare systems, when and how to book appointments, how to express their healthcare needs in English. The health care systems are based on UK health beliefs, perceptions and understanding, which are often different from their cultural understanding of health and health care.
The facilities, resources, were there but conversion factors to make them functioning “accessible health care,” was not a capability of many in the community to obtain the utility of health. In contrast most of the indigenous people were capable of gaining access.
The functioning “access to health care” in both communities was about access to timely and comprehensive health care. The conversion factors and the resources needed to turn this into a utility were different, depending on the local contexts, cultures, and health beliefs.
In both areas, poverty and its fuelling factors seem to be the major barrier to accessing health and being healthy. Because access was more than getting through the door, education was perceived as a converting factor that would enable people to access health and utilise available health resources. It was clear that the communities' definition of education was beyond formal school based programmes. The acquisition of life skills and knowledge seems essential to improving well-being. The CA helped us to hear and empathise with the individuals' beliefs and expectations.
In the UK the language of the health care systems was English, and in Kenya it was Kiswahili. Patients who do not speak the language of the health system need translation to get to and make full use of the facility. The lack of the functioning “access to health care” was therefore further restricted by the lack of the conversion factor of how to understand not just the cultural expression of health care, but also the actual conversation taking place that makes health care a utility.
Other examples of the application of Sen's capabilities approach
In both areas, the health care provider would expect the patient to comply with their advice such as eating healthier diets, using safe and clean water, proper sanitation and hygiene, living in a clean physical environment and adhering to medication. In the Kenyan community lack of access to food was as disruptive to health as the UK population's over-eating. In the Kenyan community lack of clean and safe water, hygiene, toilets and clean environment was a direct consequence of lack of infrastructure, predominantly still living as pastoralists in mud and stick constructions with no running water and a very dusty environment. Water has to be carried to the house and little is left over for personal hygiene. The water used for drinking was not always treated. It was reported that there were few latrines most of which were not deep enough and routine hand-washing was not often observed.
In the UK study area, clean water was piped into all houses and each had a water-closet toilet. Here, the instances of poor hygiene and sanitation were reported to result from poverty, and ignorance leading to lazy habits and mental health problems.
For both communities the amenities were seen by the healthcare providers as resources to reach the utility of health, but without the conversion factor of better housing for the Kenyan community, and better infrastructure and social services for both communities, it was not a utility.
We undertook a resource mapping exercise involving the communities. This made them more visible and potentially more available and offered a greater range of choice and facilitated both communities' engagement with a prioritisation exercise.
As health care professionals trained in the value of the implementation of evidence based care, it was difficult for us, the fellows, individually and as a group to accept some of the prioritisation of the community members. For instance, the decision of the community to place gender inequality and culture in a low position conflicted with what we felt to be more important. Female circumcision, early sexual debut and teenage pregnancy are products of culture and gender inequality. They are problems with clear evidence based actions but were rated by the community as “not very important” or “not important.”
The nonclinical role of the fellows was respected by the communities who accepted that we were present not as providers of clinical care but to study health needs.
| Discussion|| |
Using the CA enabled us to better understand and provide a practical illustration of how deprivation and poverty is linked to poor health. In this paper, we have exemplified the fundamental connection between deprivation, poverty and health through the emerging theme of a barrier to access to health services. In the deprived urban and rural communities access to health depends on what is available, appropriateness of the services that are available, the means through which they are accessed, the health status of the individual, their beliefs and financial resources, and their understanding of the health conversations. It also enabled them and us to appreciate the socioeconomic determinants of health and how they facilitate or hinder people's ability to access health. All too often, these elements are described in isolation with reference to a specific disease.
Despite the geographical and economic differences between the two study areas, we found a similarity in the identified health needs, their impact on the community and the possible solutions. This similarity of the issues adds weight to the concept of health as a global concern across and beyond geographical boundaries.
It is possible that the themes derived in the first community influenced those derived in the second. In both instances the themes were fed back to the communities and validated as being representative.
The results of this exercise challenged us as clinicians whose culture is to respond to different sorts of evidence. We needed to respect the results of the communities' needs at the same time feeling the need to inform them of our professional concerns in areas where they had rated them of lesser importance. This highlighted the disjunction between the communities' preferences and professional expertise. Not least in respecting the choices made but in feeling neglectful in not pointing out the “errors” of their ways. Is this confusion, clinical neglect or personal professional development? This dissonance is partly covered by the Nussbaum approach which offers a pre-set of 10 central capabilities 
As fellows we felt that by using qualitative methods to derive data from individuals and groups, informed by CA, it helped us to understand more fully community needs and requirements. The relative lack of hard data in the low income country enabled us to follow more closely the narrative rather than any epidemiological interpretation. It also gave us the courage to concentrate on the peoples' stories in a data rich society and to see how access was a problem when resources seem to be abundant. It also meant that solutions were identified and discussed in a conversational, respectful, empowering and potential sustainable manner.
Working with the CA and using a methodology that uses culturally respective attention and recording and offering a prioritisation system to help the community make choices, challenges the health professional whose education and training is based on evidence based decision making and implementation.
It was easier to define natural and respected leaders in the low income setting than in the high income country. The possible reasons for this were not explored.
Further research would be a qualitative study of the implementation of agreed recommendations to evaluate the long-term utility and sustainability of this educational project.
| Conclusion|| |
Using the CA as a theoretical framework in the data collection and/or in the analysis of the data enabled the fellows and the community members to explore, understand and apply the principles of the approach and appreciate the impact and complexity of the socioeconomic determinants of health in areas of social deprivation in both a low and high income countries. The bottom-up design and qualitative research methodology enabled a better understanding of how to make planned healthcare resources into real utilities for socially deprived communities.
The deliberate nonclinical role enabled the fellows to concentrate on learning about health and its determinants without being diverted by the imperative of clinical care.
In both Kenya and UK we saw that potential resources were not fully utilised because the capability of individuals and communities were influenced by personal, cultural and contextual factors. The fellows were able to define themes and the communities were able to prioritise them and it was clear that they were all interrelated and overlapping, as would be predicted by the CA.
This educational project using experiential methods and based on the CA enabled the fellows to develop a deep understanding of social deprivation and poverty upon health in individuals and communities. It also illustrated that between high and low income countries those who live in poverty have similar experiences, and these are the fundamental elements of global health.
Using the data and the report from this study the rural community now has a fully functioning health facility and the urban community now has a working welfare network which acts as a forum between the communities and the service providers.
Financial support and sponsorship
From NHS, Health Education Englan, East Midlands and Hughes Hall, Cambridge University UK.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2010.
Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al.
Towards a common definition of global health. Lancet 2009;373:1993-5.
Wells T. Sen's Capability Approach. Internet Encyclopedia of Philosophy; 2010. Available from: https://www.iep.utm.edu/sen-cap/
. [Last accessed on 2017 Jan 27].
Sen, A., 1999. Chapter 4 in Development as Freedom.
Oxford University Press, Oxford
Nussbaum M. Creating Capabilities. Cambridge, Mass., USA: Harvard University Press; 2011. p. 256.
Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. BMJ 1998;316:1310-3.
Donaldson C, Mooney G. Needs assessment, priority setting, and contracts for health care: An economic view. BMJ 1991;303:1529-30.
Spradley J. The Ethnographic Interview. New York: Wadsworth Publishing Co., Inc.; 1979.
Morgan D. Focus Groups as Qualitative Research. 2nd
ed. Thousand Oaks: Sage Publications; 1996. p. 88.
Jorgensen D. Participant Observation. London: Sage Publications; 1989.
Spradley J. Participant Observation. New York: Wadsworth Publishing Co., Inc.; 1980.
Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45.
Quine A, Tulinius C, Obuzor G, Ndomoto L, Nthusi N, Hibble A, et al
. Voting for Better Health in Deprived Communities; 2018. Submitted for Publication.
[Figure 1], [Figure 2]