EXPLORING CULTURAL SAFETY AND EQUITY IN CHRONIC KIDNEY DISEASE CARE ACROSS AFRICA: PROTOCOL FOR A MULTI-COUNTRY QUALITATIVE INQUIRY

Chronic kidney disease (CKD) is a growing public health concern across Africa, presenting challenges and opportunities in addressing its high prevalence and improving access to treatment. The CKD care experience is influenced by intersecting factors such as socioeconomic status, cultural beliefs, comorbidities, health system governance, and the broader interactions between health systems, other institutions, and society. Ongoing efforts to improve service delivery provide an opportunity to strengthen responses to cultural insensitivity, health system mistrust, and limited recognition of individual contexts. By actively incorporating patient perspectives into CKD care models, health inequities can be reduced and care made more responsive.

A focus on cultural safety and equity emphasizes respect for individual and collective self-determination and makes visible the power imbalances inherent in clinical encounters making exploration of cultural safety and equity in healthcare essential. This African theory-driven study seeks to explore cultural safety and equity in CKD care through a multi-country qualitative investigation, co-creating interventions with people of interest to improve care experiences and CKD outcomes across African health systems.

This is a multi-country, multi-stage, explorative study using in-depth interviews, focus group discussions, key informant interviews, care pathway mapping, and participatory action workshops, supplemented with quantitative questionnaires. Health facilities and communities in six African countries (i.e., South Africa, Nigeria, Ghana, Kenya, Uganda, Seychelles, Republic of Congo and Egypt) will be included.

Stage 1: Understanding cultural safety and equity in CKD care

We will employ a purposive sampling framework to identify adults diagnosed with CKD (stages 3-5, including those receiving and not receiving dialysis), family members/caregivers, healthcare providers (doctors, nurses, allied health professionals), and health system stakeholders (policymakers, managers, traditional leaders, community health workers).

Stage 2: Care pathway mapping

We will conduct observations of CKD care delivery in clinics/dialysis centres to understand patient-provider interactions, including observing provider behaviour (e.g., greeting styles, time spent listening, non-verbal communication) and documenting the interaction with caregivers/community members regarding the decision-making process.

Stage 3: Exploring and co-creating interventions

Building on the findings from stage 1 and 2, participatory co-design workshops will be convened in each country to identify priority areas for intervention, explore acceptable, feasible, and cultural appropriate solutions, and co-create intervention strategies.

Stage 4: Piloting testing interventions

This stage will assess the acceptability, feasibility, and cultural appropriateness of the proposed interventions, with the aim of refining for broader implementation. 

This study will provide novel insights into the lived experiences of receipt of CKD care across diverse African contexts and identify actionable strategies to make this care more inclusive, respectful, and equitable. 

The evidence generated will support advocacy for person-centred, culturally safe healthcare across the continent, supporting CKD-Africa’s strategic goal of context-relevant research.