Intersectional Experiences of Non-Communicable Diseases and Health Seeking Strategies in Informal Settlements in Freetown, Sierra Leone

This paper explores the burdens of non-communicable diseases (NCDs) in low-income settings, and how they are shaped by structural barriers including gender inequities. As Low- and Middle-Income Countries (LMICs) face epidemiological transitions towards increased NCD burdens, the challenges faced by people living with NCDs are a priority. We employed narrative inquiries to explore the lived experiences and healthcare seeking decision making practices of 15 participants living with diabetes, hypertension, and disability related to stroke in three informal settlements in Freetown. Narrative interviews were conducted through three household visits within a period of 12 weeks. We adapted the Intersectional Gender Analysis Framework for Infectious Diseases of Poverty Research to understand how poverty, gender and other axes of inequity interact with NCD burdens in informal settlements. Findings show a strong connection between poverty, gender identities and comorbidities linked to NCDs. Womens lived experiences of NCD conditions reflected historical disadvantage and patriarchal oppression, most notably through their limited financial autonomy, barriers to healthcare decision making and treatment access, compounded by gendered impacts of conflict and migration. Mens experiences were however influenced by changes in social status, due to conflict and migration, and financial instability, limiting access to healthcare. Gender differences were also key in shaping household and healthcare decision making, as gender norms and experiences of masculinities and femininities reflected the division of roles and access to resources by men and women, which in turn shaped their ability to seek early and better healthcare interventions. In conclusion, our study has shown that for people living with NCDs, gender norms and patriarchal structures reinforce power hierarchies, worsen health outcomes and deepen poverty. Healthcare interventions must consider the full range of needs and impacts of people impacted by long term illnesses and the context in which they live.