Navigating Healthcare in Displacement: A Qualitative Study of Internally Displaced Persons in Conflict-Affected Burkina Faso

Navigating Healthcare in Displacement: A Qualitative Study of Internally Displaced Persons in Conflict-Affected Burkina Faso | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navigating Healthcare in Displacement: A Qualitative Study of Internally Displaced Persons in Conflict-Affected Burkina Faso Abdoul Kader Sinka, Patrice Ngangue This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9132478/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Healthcare access in conflict-affected settings is frequently examined through structural indicators such as service availability and cost. However, less is known about how displaced populations experience and negotiate access in their daily lives. This qualitative study explores how internally displaced persons (IDPs) in the Dori health district of Burkina Faso navigate healthcare access in a context of protracted insecurity. Methods Forty semi-structured interviews were conducted with IDP leaders, healthcare providers, managers, and NGO representatives. Data were analyzed using thematic analysis guided by the Levesque conceptual framework of access to healthcare. The study involved 40 participants comprising a balanced representation (25% each) of IDP leaders, healthcare providers, health system managers, and NGO representatives. Among the professional participants, 60% possessed over five years of experience in conflict-affected health service delivery or coordination. Results Findings reveal that healthcare access operates as a negotiated and sequential process shaped by economic precarity, institutional trust, perceived discrimination, and ongoing insecurity. Participants described weighing financial costs, security risks, and anticipated treatment experiences before seeking care. Social networks functioned as informal infrastructures compensating for institutional fragility, yet potentially reproducing inequalities. Experiences of disrespect and marginalization undermined engagement, highlighting the centrality of dignity within the acceptability dimension of access. Conclusion The study contributes to theoretical debates by proposing a temporally layered understanding of access in fragile contexts, where structural and relational barriers accumulate cumulatively. These findings call for refined conceptualizations of healthcare access that account for social identity, moral economy, and institutional legitimacy in humanitarian settings. Internally displaced persons healthcare access Levesque framework Burkina Faso Background Armed conflict and protracted insecurity continue to destabilize health systems worldwide, generating large-scale internal displacement and deepening health inequities [ 1 ]. According to recent global estimates, more than 59 million people are living in situations of internal displacement, with conflict remaining a leading driver in sub-Saharan Africa [ 2 ]. Displacement disrupts livelihoods, weakens social networks, and exposes populations to heightened health risks, while simultaneously straining already fragile health systems [ 3 ]. Access to healthcare is widely recognized as a core component of universal health coverage and health system resilience [ 4 ]. However, in conflict-affected settings, access is rarely determined solely by the physical availability of services [ 5 ]. Health facilities may remain operational, yet displaced populations often face layered constraints including economic precarity, insecurity-related mobility restrictions, institutional mistrust, and social marginalization [ 6 ]. In such environments, healthcare access becomes entangled with broader survival strategies [ 3 ]. Existing research on healthcare access in fragile settings has largely relied on quantitative approaches documenting structural barriers such as cost, distance, and service availability [ 7 ]. These studies have consistently identified out-of-pocket expenditures, transportation challenges, and health workforce shortages as major determinants of reduced utilization among displaced populations [ 5 , 6 , 8 , 9 ]. While these findings are critical for policy planning, they offer limited insight into how displaced individuals interpret, experience, and negotiate these barriers in their daily lives [ 5 ]. Healthcare access is increasingly conceptualized as a multidimensional and dynamic process [ 3 , 5 ]. The framework developed by Levesque et al. proposes five interrelated dimensions—availability, accessibility, affordability, acceptability, and appropriateness—alongside corresponding individual capacities to perceive, seek, reach, pay for, and engage in care [ 10 ]. This framework has been widely cited in health services research [ 11 ]; however, empirical qualitative applications in protracted conflict settings remain limited [ 7 ]. Few studies have examined how displaced populations navigate access over time, how relational experiences such as dignity and discrimination shape engagement, and how social networks mediate institutional barriers [ 12 , 13 ] . Burkina Faso has experienced escalating insecurity since 2015, particularly in the Sahel region, resulting in substantial internal displacement [ 14 ]. By 2022, hundreds of health facilities in conflict-affected regions were reported as closed or functioning at minimal capacity, and large numbers of internally displaced persons had settled in host districts such as Dori [ 15 , 16 ]. Although humanitarian actors support health service provision, access remains uncertain and unevenly distributed [ 17 ]. Despite the scale of the crisis, there is limited qualitative evidence documenting how displaced persons experience healthcare access within this evolving context. Understanding lived experiences is critical for refining conceptual models of access and informing context-sensitive interventions [ 3 ]. Structural indicators alone cannot fully capture the ways in which economic vulnerability, insecurity, social identity, and institutional trust shape health-seeking decisions [ 3 ]. A qualitative approach is therefore necessary to illuminate the interpretive and relational dimensions of access that remain underexplored in quantitative analyses [ 18 ]. This study aims to explore how internally displaced persons in the Dori health district experience and navigate healthcare access in a conflict-affected environment. Guided by the Levesque framework, the study seeks to examine how structural conditions intersect with individual capacities and social relations to shape healthcare-seeking trajectories in protracted displacement. Methods Study Design and Justification This study employed a qualitative descriptive design using semi-structured individual interviews. A qualitative approach was selected to explore how internally displaced persons (IDPs) experience and interpret healthcare access in a conflict-affected setting. While quantitative studies can identify structural determinants of healthcare utilization, they are limited in their ability to capture the lived realities, relational dynamics, and interpretive processes underlying access decisions. Given the study’s objective to examine experiential and socially mediated dimensions of access, qualitative inquiry was deemed most appropriate [ 3 , 5 ]. The study was theoretically informed by the Levesque et al. conceptual framework of healthcare access, which conceptualizes access as a multidimensional process shaped by both health system characteristics and individual capacities [ 10 ]. Study Setting The study was conducted in the Dori health district, located in the Sahel region of Burkina Faso. Since 2015, the region has experienced escalating armed insecurity, resulting in large-scale internal displacement and substantial strain on public services, including healthcare. By 2022, the district hosted a significant number of internally displaced persons across the communes of Dori, Gorgadji, and Bani. Health facilities in the district operate under constraints including intermittent closures, shortages of healthcare personnel, increased patient loads, and security-related mobility challenges. Humanitarian organizations support service provision alongside public health authorities. Participants Participants included individuals with direct or contextual experience related to healthcare access among internally displaced populations. To capture multiple perspectives, four stakeholder groups were included: (i) internally displaced community leaders and representatives, (ii) healthcare providers working in public facilities, (iii) health system managers at district or regional level and (iv) representatives of non-governmental organizations involved in healthcare assistance. This multi-actor inclusion allowed triangulation of perspectives across user and provider levels and strengthened analytical depth. Sampling Strategy and Recruitment A purposive sampling strategy was employed to ensure variation in roles, experiences, and exposure to healthcare access challenges. Participants were selected based on their knowledge of or involvement in healthcare access processes affecting internally displaced persons. Recruitment was facilitated through collaboration with district health authorities and local humanitarian coordination structures. Potential participants were contacted directly and provided with information about the study’s purpose and procedures. Participation was voluntary. Sampling continued until thematic saturation was achieved, defined as the point at which no substantially new themes emerged from additional interviews [ 19 ]. A total of 40 semi-structured interviews were conducted, distributed approximately evenly across stakeholder categories. Inclusion Criteria Participants were eligible for inclusion in the study if they were aged 18 years or older and possessed direct experience with internally displaced populations, either as displaced persons themselves or as professionals involved in service provision or coordination. Furthermore, candidates were required to be residing or actively working within the Dori health district during the study period and could provide informed consent to participate. Conversely, individuals who were unable to provide informed consent were excluded from the study. Data Collection Data were collected between September and November 2022. Interviews were conducted in private and secure locations within health facilities, administrative offices, or community spaces, depending on participant preference and safety considerations. The semi-structured interview guides were specifically developed by the research team to address the unique context of healthcare access in the Dori health district of Burkina Faso. While the conceptual framework guiding the questions is based on the previously published Levesque et al. (2013) framework of patient-centered access to healthcare, the specific interview items and probes were tailored for this study's population (IDPs and healthcare stakeholders). The English versions of the interview are provided as Additional File 1 (Supplementary Materials). These included the participants' subjective perceptions of healthcare access and the specific economic and organizational constraints they encountered during care-seeking. Additionally, the guides probed into interpersonal experiences, such as perceived discrimination or the presence of respectful care, while also accounting for the influence of mobility and security considerations within the conflict zone. Finally, the interviews were structured to capture the various resilience strategies and navigating mechanisms IDPs employed to access services despite these systemic barriers. Interviews were conducted in languages preferred by participants, with translation support when necessary. Each interview lasted approximately 45 to 75 minutes. All interviews were audio-recorded with participant consent and transcribed verbatim. Identifying information was removed during transcription to ensure confidentiality. Field notes were recorded immediately after interviews to capture contextual observations and reflexive insights. Data Analysis Data were analyzed using thematic analysis in accordance with the six-phase framework outlined by Braun and Clarke. This process began with a thorough familiarization with the data through repeated reading of the transcripts to ensure depth of understanding. Subsequently, initial codes were generated systematically across the entire dataset, which were then collated into potential thematic categories during the search for overarching themes. These themes were rigorously reviewed to ensure internal coherence and distinctiveness between categories. The final stages involved defining and naming each theme to accurately reflect the data, culminating in the production of a cohesive analytic narrative that links the findings back to the study's conceptual framework. A hybrid deductive-inductive approach was used. Deductive coding was guided by the five dimensions of the Levesque framework (availability, accessibility, affordability, acceptability, appropriateness). Inductive coding allowed identification of emergent themes not fully captured by the framework, particularly relational and contextual dimensions specific to displacement [ 20 ]. Coding was conducted iteratively. Themes were refined through constant comparison across stakeholder groups. Reflexive discussions among the research team were used to enhance credibility and minimize interpretive bias. Ethical Considerations The study was reviewed and approved by the Comité d’Éthique pour la Recherche en Santé (CERS), which is the national ethics committee under the Ministry of Health and the Ministry of Higher Education, Research and Innovation of Burkina Faso (Protocol No. 2021-12-292, dated December 01, 2021). Administrative authorization was granted by the regional and district health authorities of the Sahel. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the relevant institutional ethics committee prior to data collection. Administrative authorization was granted by district health authorities. All participants received detailed information about the study objectives, procedures, risks, and benefits. Written informed consent was obtained prior to participation. Confidentiality was strictly maintained. Transcripts were anonymized, and audio files were stored securely. Participants were informed of their right to withdraw at any time without consequence. Given the sensitivity of displacement-related experiences, interviews were conducted with attention to psychological safety. No financial incentives were provided. Results Participant Characteristics A total of 40 participants were interviewed. Participants represented four stakeholder groups: internally displaced community leaders (n = 10), healthcare providers (n = 10), district or regional health managers (n = 10), and representatives of non-governmental organizations involved in health assistance (n = 10). Participants ranged in age from 28 to 58 years. The majority were male, reflecting the predominance of men in formal leadership and health system roles within the district. Professional participants had between 2 and 15 years of experience working in conflict-affected contexts (Table 1 ). Table 1 Sociodemographic Characteristics of Qualitative Participants (N = 40) Characteristic n (%) Gender Male 28 (70%) Female 12 (30%) Participant Category IDP leaders/community representatives 10 (25%) Healthcare providers 10 (25%) Health system managers 10 (25%) NGO representatives 10 (25%) Years of experience (professionals) 2–5 years 12 (40%) 6–10 years 10 (33%) > 10 years 8 (27%) Participants provided diverse yet convergent perspectives on healthcare access in displacement. Thematic Findings Five major themes emerged from the analysis. Access Exists on Paper, Not in Practice Participants repeatedly described a disconnect between the formal existence of healthcare services and their actual functionality. While facilities were geographically present, their operational stability was perceived as inconsistent and unreliable. “The health center is there, but sometimes there are no medicines or no staff. So even if you go, you may not receive care.” (Healthcare provider, male, 36 years) “They say services are available, but when people arrive, they are told to come back another day.” (IDP leader, male, 44 years) This perception reveals that availability, as defined structurally, does not necessarily translate into effective access. Participants emphasized unpredictability—services could be open but not fully functional, or medications could be unavailable. Such uncertainty created hesitation in care-seeking decisions, particularly when the cost of transportation or lost income was high. Long waiting times were also interpreted as a signal of systemic fragility: “You can wait the whole day, and maybe you are not seen. People get discouraged.” (Female IDP representative, 31 years) “We have too many patients and not enough staff. Waiting time becomes inevitable.” (District health manager, male, 42 years) Waiting was not merely logistical inconvenience. It was experienced as wasted time in contexts where daily survival required constant labor and resource mobilization. Participants described waiting time as discouraging and, in some cases, humiliating—particularly when combined with perceptions of unequal treatment. Thus, availability emerged as a conditional and fragile dimension of access rather than a stable guarantee of care. Economic Precarity and Competing Survival Priorities Affordability emerged as a dominant and cross-cutting determinant. Participants described healthcare decisions as embedded within broader household survival strategies. “If you don’t have money, you just endure the illness. You first think about feeding your family.” (Male IDP leader, 39 years) “Sometimes we delay going to the hospital because even transport costs are too much.” (Female IDP representative, 28 years) Economic precarity was not limited to consultation fees. Participants described transportation costs, medication expenses, and opportunity costs (lost income) as cumulative burdens. Illness was weighed against food security, shelter needs, and school expenses. Healthcare providers confirmed this dynamic: “Many displaced families cannot pay. Even small fees are heavy for them.” (Healthcare provider, female, 34 years) “You see patients who come very late because they were trying to gather money.” (Healthcare provider, male, 38 years) Delays in seeking care were therefore not interpreted as negligence but as forced trade-offs. Participants described enduring symptoms, attempting self-medication, or relying on informal remedies before seeking formal care. Affordability thus functioned both as an economic constraint and as a moral calculus, where illness threatened already fragile household stability. Discrimination, Dignity, and Trust Relational experiences emerged as central to healthcare engagement. While overt discrimination was not universally reported, subtle forms of marginalization were described as impactful. “Some displaced people feel they are not treated the same as others.” (NGO representative, male, 41 years) “When you feel looked down on, you don’t feel comfortable coming back.” (Female IDP leader, 35 years) Participants described moments where tone of voice, body language, or prioritization practices conveyed implicit hierarchy. “Sometimes it is not direct discrimination, but you feel the difference in how you are spoken to.” (IDP representative, male, 30 years) Trust was described as fragile and socially contagious: “If one bad experience happens, people talk about it. Then others are afraid.” (Health manager, female, 45 years) These narratives highlight that acceptability extends beyond cultural compatibility to include recognition and dignity. Feeling respected—or disrespected—directly influenced willingness to re-engage with care. Trust functioned as a mediating mechanism between structural access and actual utilization. Insecurity as a Structural Constraint Insecurity shaped mobility patterns and timing of care-seeking. Participants described calculating risks before traveling to health facilities. “We cannot travel at certain times because of fear. Security comes first.” (Male IDP leader, 42 years) “If there is an alert, people prefer to stay home even if they are sick.” (NGO representative, female, 37 years) Insecurity did not merely disrupt services; it reshaped daily routines. Health-seeking became contingent upon perceived safety conditions. Healthcare providers acknowledged these challenges: “Sometimes patients do not come because the road is not safe.” (Healthcare provider, male, 40 years) “Insecurity limits outreach activities and referral systems.” (Health manager, male, 47 years) Insecurity therefore intersected with availability and accessibility, reinforcing delays and non-utilization. Healthcare access in this context was embedded within broader security risk calculations. Social Networks as Informal Gateways to Care Social capital functioned as an informal mechanism for overcoming structural barriers. “If you know someone inside the center, things move faster.” (IDP leader, male, 44 years) “Community leaders often help families navigate the system.” (NGO representative, male, 39 years) Relatives and neighbors pooled resources: “Relatives sometimes collect money together to help someone go to the hospital.” (Female IDP representative, 33 years) “Without community solidarity, many people would not access care.” (Healthcare provider, female, 35 years) Social networks facilitated financial support, information flow, and mediation with providers. However, reliance on networks also introduced stratification: “Those without connections suffer more.” (Health manager, male, 46 years) Thus, social capital acted as both protective and differentiating, mitigating structural barriers while potentially reproducing inequalities within displaced communities. Discussion This study aimed to explore how internally displaced persons (IDPs) in the Dori health district of Burkina Faso experience and navigate healthcare access within a conflict-affected environment. Guided by the Levesque framework, we examined how structural conditions intersect with individual capacities and social relations to shape healthcare-seeking trajectories in protracted displacement. By adopting a qualitative approach, the study illuminates the lived, relational, and processual dimensions of access that remain underexplored in predominantly quantitative analyses of fragile health systems. Overall, the findings demonstrate that healthcare access in displacement is not merely constrained by structural deficits but is experienced as a negotiated and cumulative process [ 3 ]. Participants described a profound disconnect between the formal availability of services and their practical functionality. Health facilities existed in a physical sense, yet inconsistent medication supply, staff shortages, and long waiting times rendered access fragile and inherently uncertain. Economic precarity emerged as a central determinant of care-seeking behavior, with healthcare decisions embedded within broader survival strategies where food security, shelter, and income generation often took precedence over medical care [ 8 ]. Affordability was therefore experienced not only as a financial limitation but as a moral burden threatening household stability, where the cost of care was weighed against the very survival of the family unit [ 21 ]. Relational experiences further shaped engagement with health services, as participants emphasized the importance of dignity, respect, and recognition in their interactions with providers. In this sense, acceptability extended beyond cultural compatibility to encompass trust and perceived fairness, suggesting that the clinical encounter is a site of symbolic negotiation [ 6 , 18 ]. At the same time, insecurity influenced both mobility and the timing of care-seeking, embedding healthcare access within broader risk calculations linked to violence and displacement [ 5 ]. Finally, social networks emerged as informal infrastructures that helped mitigate structural barriers; while social capital facilitated navigation of the health system, it also introduced new forms of internal stratification among displaced populations. Taken together, these findings suggest that healthcare access operates as a layered and sequential process in which barriers accumulate and interact over time, revealing a complex landscape where structural availability collides with lived precarity, relational ruptures, and adaptive survival strategies [ 3 ]. The prominence of financial barriers aligns with extensive literature documenting the impact of out-of-pocket payments on healthcare utilization in fragile and conflict-affected settings, yet this study extends existing evidence by demonstrating how affordability is socially and morally interpreted [ 8 ]. Healthcare decisions unfolded within a zero-sum survival calculus in which medications competed with food for children or rent for shelter, manifesting not only as cash scarcity but as moral distress. This perspective reinforces scholarship on the moral economy of care in contexts of scarcity, positioning access within household resilience rather than isolated health transactions [ 3 ]. Furthermore, our findings highlight the tension between formal service availability and practical functionality, often perceived by participants as a form of “paper availability [ 11 ].” Although health facilities remained physically present, chronic medication stockouts and staff absenteeism undermined institutional confidence, forcing many households to ration visits or seek distant alternatives [ 3 , 8 ]. This illustrates how the accommodation dimension of access is highly contingent and often illusory in conflict-affected environments [ 11 ]. Relational dimensions of care emerged as central determinants of continued engagement, where experiences of disrespect or perceived discrimination discouraged subsequent care-seeking, whereas dignified encounters fostered the trust necessary for return visits [ 6 ]. These dynamics resonate with literature emphasizing the importance of institutional legitimacy in shaping healthcare utilization in fragile contexts [ 6 , 22 , 23 ]. Moreover, insecurity profoundly structured the temporal and spatial dimensions of access, as curfews and the risk of ambush constrained mobility and forced individuals to time healthcare visits around perceived “windows of safety [ 3 , 5 ].” This transformation of accessibility into a risk calculation suggests that geographic distance is a fluid, rather than static, metric in war zones [ 5 , 24 ]. Finally, the role of social networks as parallel infrastructures—comprising kinship, religious leaders, and savings groups—highlights a dual function: while they mobilize resources despite systemic barriers, they also produce internal stratifications where those with weaker social ties face intensified exclusion [ 25 ]. These findings ultimately complicate narratives of health system resilience that equate the continued presence of facilities with effective access [ 26 ]. Even when services remain operational, experiential and organizational dimensions may undermine their utilization, supporting arguments that resilience must extend beyond infrastructural continuity to include relational legitimacy and the lived realities of displaced populations [ 27 , 28 ]. This study underscores the need for conceptual refinements in models of healthcare access applied to conflict settings. The Levesque framework provides a valuable structure, yet our findings suggest that in protracted displacement contexts, dimensions of access operate cumulatively and sequentially rather than independently [ 10 ]. Future research should examine longitudinal trajectories of healthcare access to capture how specific barriers evolve over time and investigate intra-community inequalities mediated by varying levels of social capital [ 29 ]. Additionally, it is essential to explore how host–displaced social dynamics shape relational trust in healthcare settings and to integrate qualitative approaches more systematically into fragile health system analysis to provide a deeper understanding of the lived experiences of vulnerable populations [ 30 ]. The findings highlight that improving healthcare access for displaced populations requires multidimensional interventions [ 31 ]. First, reducing financial barriers remains essential. Targeted fee exemptions, transportation subsidies, or emergency risk-pooling mechanisms may mitigate economic constraints [ 32 ]. Second, organizational improvements—such as reducing waiting times and strengthening medication supply chains—could significantly enhance effective access without requiring major infrastructural expansion [ 33 ]. Third, respectful communication and anti-discrimination training for healthcare staff should be prioritized. Relational quality is not peripheral but central to engagement [ 34 ]. Fourth, interventions leveraging community leaders and social networks should be carefully designed to avoid reinforcing internal inequalities. Ultimately, policies must recognize that healthcare access in displacement is embedded within broader structural vulnerability and insecurity [ 35 ]. Strengths and Limitations This study has several strengths. It draws on diverse stakeholder perspectives, enabling triangulation across user and provider experiences. The use of a well-established conceptual framework supports analytical coherence, while the thematic approach allowed identification of context-specific dimensions. However, limitations must be acknowledged. The study was conducted in a single district, which may limit transferability to other conflict settings. Social desirability bias may have influenced participant responses, particularly among professionals. Additionally, as a qualitative study, findings cannot establish prevalence or statistical association. Despite these limitations, the study provides a nuanced and contextually grounded understanding of healthcare access in protracted displacement. Conclusion This study demonstrates that healthcare access in protracted displacement is a layered, socially mediated process rather than a mere function of service availability. Among IDPs in the Dori health district, effective access is shaped by the convergence of economic precarity, institutional fragility, and relational trust. Displaced individuals must navigate complex trade-offs between financial risk, security constraints, and household survival, making the decision to seek care a socially embedded act rather than a purely biomedical one. The findings highlight that affordability, acceptability, and accessibility interact sequentially in fragile environments, where dignity and institutional legitimacy are central to health system engagement. These insights suggest that health systems in conflict-affected regions must move beyond simple service restoration toward multidimensional strategies that integrate economic protection with high-quality, relational care. Ultimately, achieving equitable health coverage in the Sahel requires a fundamental recognition of the lived realities and ongoing negotiations of displaced populations within uncertain and unequal environments. Declarations Ethics approval and consent to participate All methods in this study were performed in accordance with the Declaration of Helsinki. The study protocol and all related data collection and consent tools were reviewed and approved by the Comité d’Éthique pour la Recherche en Santé (CERS), which is the national ethics committee under the Ministry of Health and the Ministry of Higher Education, Research and Innovation of Burkina Faso (Protocol No. 2021-12-292, dated December 01, 2021). Administrative authorization was granted by the regional and district health authorities of the Sahel. Prior to enrollment, the objectives and procedures of the study were explained to all participants in their local language where necessary. Informed consent was obtained from all participants involved in the study. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. All costs associated with data collection and analysis were covered by the authors. The authors declare that no external funders were involved in the study design, data collection, analysis, or the decision to submit the paper for publication. Author Contribution AKS and PN contributed to the conception and design of the study. AKS conducted the literature review, managed the data, and performed the primary analysis. The interpretation of the results was carried out by AKS and PN. PN drafted the initial manuscript, and both AKS and PN were involved in the review, editing, and supervision of the final article. All authors have read and approved the final version for submission. Acknowledgement The authors would like to thank all the study participants who shared their experiences despite the challenging security context. We also extend our gratitude to the health and social service administrators in the Dori health district and the provincial humanitarian coordinators for their administrative support and assistance during the recruitment process. Data Availability The datasets generated and analyzed during the current study are not publicly available due to the sensitive nature of the data involving vulnerable populations in a conflict-affected region and the need to ensure participant confidentiality. However, anonymized data may be obtained from the corresponding author upon reasonable request. References Arage MW et al. Exploring the health consequences of armed conflict: the perspective of Northeast Ethiopia, 2022: a qualitative study. BMC Public Health, 2023. 23(1): p. 2078. Internal Displacement Monitoring Centre (IDMC). Global Report on Internal Displacement 2025. IDMC; 2025. Cantor D, et al. Understanding the health needs of internally displaced persons: A scoping review. 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Supplementary Files INTERVIEWGUIDES.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviews received at journal 26 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor invited by journal 20 Mar, 2026 Editor assigned by journal 20 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 19 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9132478","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627956136,"identity":"50c5af03-028e-4a4a-b531-d61cfc0d71bf","order_by":0,"name":"Abdoul Kader Sinka","email":"data:image/png;base64,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","orcid":"","institution":"World Health Organization","correspondingAuthor":true,"prefix":"","firstName":"Abdoul","middleName":"Kader","lastName":"Sinka","suffix":""},{"id":627956137,"identity":"aff046a7-4b57-4388-b662-dc73709ab8f4","order_by":1,"name":"Patrice Ngangue","email":"","orcid":"","institution":"Université Laval","correspondingAuthor":false,"prefix":"","firstName":"Patrice","middleName":"","lastName":"Ngangue","suffix":""}],"badges":[],"createdAt":"2026-03-16 03:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9132478/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9132478/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107707797,"identity":"b5b43c27-d568-4160-8bd4-e160de46ac33","added_by":"auto","created_at":"2026-04-24 09:21:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":236443,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9132478/v1/ba9e1ec3-a844-4126-bfe8-a145ebc59493.pdf"},{"id":107665649,"identity":"93c2dde5-ffce-4950-b764-288d7a33d288","added_by":"auto","created_at":"2026-04-23 18:44:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23977,"visible":true,"origin":"","legend":"","description":"","filename":"INTERVIEWGUIDES.docx","url":"https://assets-eu.researchsquare.com/files/rs-9132478/v1/7881ca86fa67f1c4f5b49252.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Navigating Healthcare in Displacement: A Qualitative Study of Internally Displaced Persons in Conflict-Affected Burkina Faso","fulltext":[{"header":"Background","content":"\u003cp\u003eArmed conflict and protracted insecurity continue to destabilize health systems worldwide, generating large-scale internal displacement and deepening health inequities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to recent global estimates, more than 59\u0026nbsp;million people are living in situations of internal displacement, with conflict remaining a leading driver in sub-Saharan Africa [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Displacement disrupts livelihoods, weakens social networks, and exposes populations to heightened health risks, while simultaneously straining already fragile health systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccess to healthcare is widely recognized as a core component of universal health coverage and health system resilience [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, in conflict-affected settings, access is rarely determined solely by the physical availability of services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Health facilities may remain operational, yet displaced populations often face layered constraints including economic precarity, insecurity-related mobility restrictions, institutional mistrust, and social marginalization [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In such environments, healthcare access becomes entangled with broader survival strategies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExisting research on healthcare access in fragile settings has largely relied on quantitative approaches documenting structural barriers such as cost, distance, and service availability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These studies have consistently identified out-of-pocket expenditures, transportation challenges, and health workforce shortages as major determinants of reduced utilization among displaced populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While these findings are critical for policy planning, they offer limited insight into how displaced individuals interpret, experience, and negotiate these barriers in their daily lives [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealthcare access is increasingly conceptualized as a multidimensional and dynamic process [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The framework developed by Levesque et al. proposes five interrelated dimensions\u0026mdash;availability, accessibility, affordability, acceptability, and appropriateness\u0026mdash;alongside corresponding individual capacities to perceive, seek, reach, pay for, and engage in care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This framework has been widely cited in health services research [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; however, empirical qualitative applications in protracted conflict settings remain limited [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Few studies have examined how displaced populations navigate access over time, how relational experiences such as dignity and discrimination shape engagement, and how social networks mediate institutional barriers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eBurkina Faso has experienced escalating insecurity since 2015, particularly in the Sahel region, resulting in substantial internal displacement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By 2022, hundreds of health facilities in conflict-affected regions were reported as closed or functioning at minimal capacity, and large numbers of internally displaced persons had settled in host districts such as Dori [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although humanitarian actors support health service provision, access remains uncertain and unevenly distributed [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Despite the scale of the crisis, there is limited qualitative evidence documenting how displaced persons experience healthcare access within this evolving context.\u003c/p\u003e \u003cp\u003eUnderstanding lived experiences is critical for refining conceptual models of access and informing context-sensitive interventions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Structural indicators alone cannot fully capture the ways in which economic vulnerability, insecurity, social identity, and institutional trust shape health-seeking decisions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A qualitative approach is therefore necessary to illuminate the interpretive and relational dimensions of access that remain underexplored in quantitative analyses [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aims to explore how internally displaced persons in the Dori health district experience and navigate healthcare access in a conflict-affected environment. Guided by the Levesque framework, the study seeks to examine how structural conditions intersect with individual capacities and social relations to shape healthcare-seeking trajectories in protracted displacement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Justification\u003c/h2\u003e \u003cp\u003eThis study employed a qualitative descriptive design using semi-structured individual interviews. A qualitative approach was selected to explore how internally displaced persons (IDPs) experience and interpret healthcare access in a conflict-affected setting. While quantitative studies can identify structural determinants of healthcare utilization, they are limited in their ability to capture the lived realities, relational dynamics, and interpretive processes underlying access decisions. Given the study\u0026rsquo;s objective to examine experiential and socially mediated dimensions of access, qualitative inquiry was deemed most appropriate [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study was theoretically informed by the Levesque et al. conceptual framework of healthcare access, which conceptualizes access as a multidimensional process shaped by both health system characteristics and individual capacities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in the Dori health district, located in the Sahel region of Burkina Faso. Since 2015, the region has experienced escalating armed insecurity, resulting in large-scale internal displacement and substantial strain on public services, including healthcare. By 2022, the district hosted a significant number of internally displaced persons across the communes of Dori, Gorgadji, and Bani.\u003c/p\u003e \u003cp\u003eHealth facilities in the district operate under constraints including intermittent closures, shortages of healthcare personnel, increased patient loads, and security-related mobility challenges. Humanitarian organizations support service provision alongside public health authorities.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eParticipants included individuals with direct or contextual experience related to healthcare access among internally displaced populations. To capture multiple perspectives, four stakeholder groups were included: (i) internally displaced community leaders and representatives, (ii) healthcare providers working in public facilities, (iii) health system managers at district or regional level and (iv) representatives of non-governmental organizations involved in healthcare assistance. This multi-actor inclusion allowed triangulation of perspectives across user and provider levels and strengthened analytical depth.\u003c/p\u003e\n\u003ch3\u003eSampling Strategy and Recruitment\u003c/h3\u003e\n\u003cp\u003eA purposive sampling strategy was employed to ensure variation in roles, experiences, and exposure to healthcare access challenges. Participants were selected based on their knowledge of or involvement in healthcare access processes affecting internally displaced persons.\u003c/p\u003e \u003cp\u003eRecruitment was facilitated through collaboration with district health authorities and local humanitarian coordination structures. Potential participants were contacted directly and provided with information about the study\u0026rsquo;s purpose and procedures. Participation was voluntary.\u003c/p\u003e \u003cp\u003eSampling continued until thematic saturation was achieved, defined as the point at which no substantially new themes emerged from additional interviews [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A total of 40 semi-structured interviews were conducted, distributed approximately evenly across stakeholder categories.\u003c/p\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were eligible for inclusion in the study if they were aged 18 years or older and possessed direct experience with internally displaced populations, either as displaced persons themselves or as professionals involved in service provision or coordination. Furthermore, candidates were required to be residing or actively working within the Dori health district during the study period and could provide informed consent to participate. Conversely, individuals who were unable to provide informed consent were excluded from the study.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData were collected between September and November 2022. Interviews were conducted in private and secure locations within health facilities, administrative offices, or community spaces, depending on participant preference and safety considerations.\u003c/p\u003e \u003cp\u003eThe semi-structured interview guides were specifically developed by the research team to address the unique context of healthcare access in the Dori health district of Burkina Faso. While the conceptual framework guiding the questions is based on the previously published Levesque et al. (2013) framework of patient-centered access to healthcare, the specific interview items and probes were tailored for this study's population (IDPs and healthcare stakeholders). The English versions of the interview are provided as Additional File 1 (Supplementary Materials). These included the participants' subjective perceptions of healthcare access and the specific economic and organizational constraints they encountered during care-seeking. Additionally, the guides probed into interpersonal experiences, such as perceived discrimination or the presence of respectful care, while also accounting for the influence of mobility and security considerations within the conflict zone. Finally, the interviews were structured to capture the various resilience strategies and navigating mechanisms IDPs employed to access services despite these systemic barriers.\u003c/p\u003e \u003cp\u003e Interviews were conducted in languages preferred by participants, with translation support when necessary. Each interview lasted approximately 45 to 75 minutes. All interviews were audio-recorded with participant consent and transcribed verbatim. Identifying information was removed during transcription to ensure confidentiality. Field notes were recorded immediately after interviews to capture contextual observations and reflexive insights.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using thematic analysis in accordance with the six-phase framework outlined by Braun and Clarke. This process began with a thorough familiarization with the data through repeated reading of the transcripts to ensure depth of understanding. Subsequently, initial codes were generated systematically across the entire dataset, which were then collated into potential thematic categories during the search for overarching themes. These themes were rigorously reviewed to ensure internal coherence and distinctiveness between categories. The final stages involved defining and naming each theme to accurately reflect the data, culminating in the production of a cohesive analytic narrative that links the findings back to the study's conceptual framework.\u003c/p\u003e \u003cp\u003eA hybrid deductive-inductive approach was used. Deductive coding was guided by the five dimensions of the Levesque framework (availability, accessibility, affordability, acceptability, appropriateness). Inductive coding allowed identification of emergent themes not fully captured by the framework, particularly relational and contextual dimensions specific to displacement [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Coding was conducted iteratively. Themes were refined through constant comparison across stakeholder groups. Reflexive discussions among the research team were used to enhance credibility and minimize interpretive bias.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study was reviewed and approved by the Comit\u0026eacute; d\u0026rsquo;\u0026Eacute;thique pour la Recherche en Sant\u0026eacute; (CERS), which is the national ethics committee under the Ministry of Health and the Ministry of Higher Education, Research and Innovation of Burkina Faso (Protocol No. 2021-12-292, dated December 01, 2021). Administrative authorization was granted by the regional and district health authorities of the Sahel.\u003c/p\u003e \u003cp\u003e The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the relevant institutional ethics committee prior to data collection. Administrative authorization was granted by district health authorities.\u003c/p\u003e \u003cp\u003eAll participants received detailed information about the study objectives, procedures, risks, and benefits. Written informed consent was obtained prior to participation.\u003c/p\u003e \u003cp\u003eConfidentiality was strictly maintained. Transcripts were anonymized, and audio files were stored securely. Participants were informed of their right to withdraw at any time without consequence.\u003c/p\u003e \u003cp\u003eGiven the sensitivity of displacement-related experiences, interviews were conducted with attention to psychological safety. No financial incentives were provided.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 40 participants were interviewed. Participants represented four stakeholder groups: internally displaced community leaders (n\u0026thinsp;=\u0026thinsp;10), healthcare providers (n\u0026thinsp;=\u0026thinsp;10), district or regional health managers (n\u0026thinsp;=\u0026thinsp;10), and representatives of non-governmental organizations involved in health assistance (n\u0026thinsp;=\u0026thinsp;10). Participants ranged in age from 28 to 58 years. The majority were male, reflecting the predominance of men in formal leadership and health system roles within the district. Professional participants had between 2 and 15 years of experience working in conflict-affected contexts (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic Characteristics of Qualitative Participants (N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (70%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant Category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDP leaders/community representatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth system managers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGO representatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience (professionals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants provided diverse yet convergent perspectives on healthcare access in displacement.\u003c/p\u003e \u003cp\u003eThematic Findings\u003c/p\u003e \u003cp\u003eFive major themes emerged from the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAccess Exists on Paper, Not in Practice\u003c/h2\u003e \u003cp\u003eParticipants repeatedly described a disconnect between the formal existence of healthcare services and their actual functionality. While facilities were geographically present, their operational stability was perceived as inconsistent and unreliable.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The health center is there, but sometimes there are no medicines or no staff. So even if you go, you may not receive care.\u0026rdquo; (Healthcare provider, male, 36 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;They say services are available, but when people arrive, they are told to come back another day.\u0026rdquo; (IDP leader, male, 44 years)\u003c/p\u003e \u003cp\u003eThis perception reveals that availability, as defined structurally, does not necessarily translate into effective access. Participants emphasized unpredictability\u0026mdash;services could be open but not fully functional, or medications could be unavailable. Such uncertainty created hesitation in care-seeking decisions, particularly when the cost of transportation or lost income was high.\u003c/p\u003e \u003cp\u003eLong waiting times were also interpreted as a signal of systemic fragility:\u003c/p\u003e \u003cp\u003e\u0026ldquo;You can wait the whole day, and maybe you are not seen. People get discouraged.\u0026rdquo; (Female IDP representative, 31 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;We have too many patients and not enough staff. Waiting time becomes inevitable.\u0026rdquo; (District health manager, male, 42 years)\u003c/p\u003e \u003cp\u003eWaiting was not merely logistical inconvenience. It was experienced as wasted time in contexts where daily survival required constant labor and resource mobilization. Participants described waiting time as discouraging and, in some cases, humiliating\u0026mdash;particularly when combined with perceptions of unequal treatment.\u003c/p\u003e \u003cp\u003eThus, availability emerged as a conditional and fragile dimension of access rather than a stable guarantee of care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEconomic Precarity and Competing Survival Priorities\u003c/h2\u003e \u003cp\u003eAffordability emerged as a dominant and cross-cutting determinant. Participants described healthcare decisions as embedded within broader household survival strategies.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If you don\u0026rsquo;t have money, you just endure the illness. You first think about feeding your family.\u0026rdquo; (Male IDP leader, 39 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes we delay going to the hospital because even transport costs are too much.\u0026rdquo; (Female IDP representative, 28 years)\u003c/p\u003e \u003cp\u003eEconomic precarity was not limited to consultation fees. Participants described transportation costs, medication expenses, and opportunity costs (lost income) as cumulative burdens. Illness was weighed against food security, shelter needs, and school expenses.\u003c/p\u003e \u003cp\u003eHealthcare providers confirmed this dynamic:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Many displaced families cannot pay. Even small fees are heavy for them.\u0026rdquo; (Healthcare provider, female, 34 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;You see patients who come very late because they were trying to gather money.\u0026rdquo; (Healthcare provider, male, 38 years)\u003c/p\u003e \u003cp\u003eDelays in seeking care were therefore not interpreted as negligence but as forced trade-offs. Participants described enduring symptoms, attempting self-medication, or relying on informal remedies before seeking formal care.\u003c/p\u003e \u003cp\u003eAffordability thus functioned both as an economic constraint and as a moral calculus, where illness threatened already fragile household stability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDiscrimination, Dignity, and Trust\u003c/h2\u003e \u003cp\u003eRelational experiences emerged as central to healthcare engagement. While overt discrimination was not universally reported, subtle forms of marginalization were described as impactful.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Some displaced people feel they are not treated the same as others.\u0026rdquo; (NGO representative, male, 41 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;When you feel looked down on, you don\u0026rsquo;t feel comfortable coming back.\u0026rdquo; (Female IDP leader, 35 years)\u003c/p\u003e \u003cp\u003e Participants described moments where tone of voice, body language, or prioritization practices conveyed implicit hierarchy.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes it is not direct discrimination, but you feel the difference in how you are spoken to.\u0026rdquo; (IDP representative, male, 30 years)\u003c/p\u003e \u003cp\u003eTrust was described as fragile and socially contagious:\u003c/p\u003e \u003cp\u003e\u0026ldquo;If one bad experience happens, people talk about it. Then others are afraid.\u0026rdquo; (Health manager, female, 45 years)\u003c/p\u003e \u003cp\u003eThese narratives highlight that acceptability extends beyond cultural compatibility to include recognition and dignity. Feeling respected\u0026mdash;or disrespected\u0026mdash;directly influenced willingness to re-engage with care.\u003c/p\u003e \u003cp\u003eTrust functioned as a mediating mechanism between structural access and actual utilization.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eInsecurity as a Structural Constraint\u003c/h2\u003e \u003cp\u003eInsecurity shaped mobility patterns and timing of care-seeking. Participants described calculating risks before traveling to health facilities.\u003c/p\u003e \u003cp\u003e\u0026ldquo;We cannot travel at certain times because of fear. Security comes first.\u0026rdquo; (Male IDP leader, 42 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;If there is an alert, people prefer to stay home even if they are sick.\u0026rdquo; (NGO representative, female, 37 years)\u003c/p\u003e \u003cp\u003eInsecurity did not merely disrupt services; it reshaped daily routines. Health-seeking became contingent upon perceived safety conditions.\u003c/p\u003e \u003cp\u003eHealthcare providers acknowledged these challenges:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes patients do not come because the road is not safe.\u0026rdquo; (Healthcare provider, male, 40 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Insecurity limits outreach activities and referral systems.\u0026rdquo; (Health manager, male, 47 years)\u003c/p\u003e \u003cp\u003eInsecurity therefore intersected with availability and accessibility, reinforcing delays and non-utilization.\u003c/p\u003e \u003cp\u003eHealthcare access in this context was embedded within broader security risk calculations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSocial Networks as Informal Gateways to Care\u003c/h2\u003e \u003cp\u003eSocial capital functioned as an informal mechanism for overcoming structural barriers.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If you know someone inside the center, things move faster.\u0026rdquo; (IDP leader, male, 44 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Community leaders often help families navigate the system.\u0026rdquo; (NGO representative, male, 39 years)\u003c/p\u003e \u003cp\u003eRelatives and neighbors pooled resources:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Relatives sometimes collect money together to help someone go to the hospital.\u0026rdquo; (Female IDP representative, 33 years)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Without community solidarity, many people would not access care.\u0026rdquo; (Healthcare provider, female, 35 years)\u003c/p\u003e \u003cp\u003eSocial networks facilitated financial support, information flow, and mediation with providers. However, reliance on networks also introduced stratification:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Those without connections suffer more.\u0026rdquo; (Health manager, male, 46 years)\u003c/p\u003e \u003cp\u003eThus, social capital acted as both protective and differentiating, mitigating structural barriers while potentially reproducing inequalities within displaced communities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore how internally displaced persons (IDPs) in the Dori health district of Burkina Faso experience and navigate healthcare access within a conflict-affected environment. Guided by the Levesque framework, we examined how structural conditions intersect with individual capacities and social relations to shape healthcare-seeking trajectories in protracted displacement. By adopting a qualitative approach, the study illuminates the lived, relational, and processual dimensions of access that remain underexplored in predominantly quantitative analyses of fragile health systems.\u003c/p\u003e \u003cp\u003eOverall, the findings demonstrate that healthcare access in displacement is not merely constrained by structural deficits but is experienced as a negotiated and cumulative process [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Participants described a profound disconnect between the formal availability of services and their practical functionality. Health facilities existed in a physical sense, yet inconsistent medication supply, staff shortages, and long waiting times rendered access fragile and inherently uncertain. Economic precarity emerged as a central determinant of care-seeking behavior, with healthcare decisions embedded within broader survival strategies where food security, shelter, and income generation often took precedence over medical care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Affordability was therefore experienced not only as a financial limitation but as a moral burden threatening household stability, where the cost of care was weighed against the very survival of the family unit [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Relational experiences further shaped engagement with health services, as participants emphasized the importance of dignity, respect, and recognition in their interactions with providers. In this sense, acceptability extended beyond cultural compatibility to encompass trust and perceived fairness, suggesting that the clinical encounter is a site of symbolic negotiation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. At the same time, insecurity influenced both mobility and the timing of care-seeking, embedding healthcare access within broader risk calculations linked to violence and displacement [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Finally, social networks emerged as informal infrastructures that helped mitigate structural barriers; while social capital facilitated navigation of the health system, it also introduced new forms of internal stratification among displaced populations. Taken together, these findings suggest that healthcare access operates as a layered and sequential process in which barriers accumulate and interact over time, revealing a complex landscape where structural availability collides with lived precarity, relational ruptures, and adaptive survival strategies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The prominence of financial barriers aligns with extensive literature documenting the impact of out-of-pocket payments on healthcare utilization in fragile and conflict-affected settings, yet this study extends existing evidence by demonstrating how affordability is socially and morally interpreted [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Healthcare decisions unfolded within a zero-sum survival calculus in which medications competed with food for children or rent for shelter, manifesting not only as cash scarcity but as moral distress. This perspective reinforces scholarship on the moral economy of care in contexts of scarcity, positioning access within household resilience rather than isolated health transactions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, our findings highlight the tension between formal service availability and practical functionality, often perceived by participants as a form of \u0026ldquo;paper availability [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u0026rdquo; Although health facilities remained physically present, chronic medication stockouts and staff absenteeism undermined institutional confidence, forcing many households to ration visits or seek distant alternatives [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This illustrates how the accommodation dimension of access is highly contingent and often illusory in conflict-affected environments [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Relational dimensions of care emerged as central determinants of continued engagement, where experiences of disrespect or perceived discrimination discouraged subsequent care-seeking, whereas dignified encounters fostered the trust necessary for return visits [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These dynamics resonate with literature emphasizing the importance of institutional legitimacy in shaping healthcare utilization in fragile contexts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Moreover, insecurity profoundly structured the temporal and spatial dimensions of access, as curfews and the risk of ambush constrained mobility and forced individuals to time healthcare visits around perceived \u0026ldquo;windows of safety [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u0026rdquo; This transformation of accessibility into a risk calculation suggests that geographic distance is a fluid, rather than static, metric in war zones [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Finally, the role of social networks as parallel infrastructures\u0026mdash;comprising kinship, religious leaders, and savings groups\u0026mdash;highlights a dual function: while they mobilize resources despite systemic barriers, they also produce internal stratifications where those with weaker social ties face intensified exclusion [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These findings ultimately complicate narratives of health system resilience that equate the continued presence of facilities with effective access [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Even when services remain operational, experiential and organizational dimensions may undermine their utilization, supporting arguments that resilience must extend beyond infrastructural continuity to include relational legitimacy and the lived realities of displaced populations [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study underscores the need for conceptual refinements in models of healthcare access applied to conflict settings. The Levesque framework provides a valuable structure, yet our findings suggest that in protracted displacement contexts, dimensions of access operate cumulatively and sequentially rather than independently [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Future research should examine longitudinal trajectories of healthcare access to capture how specific barriers evolve over time and investigate intra-community inequalities mediated by varying levels of social capital [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additionally, it is essential to explore how host\u0026ndash;displaced social dynamics shape relational trust in healthcare settings and to integrate qualitative approaches more systematically into fragile health system analysis to provide a deeper understanding of the lived experiences of vulnerable populations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings highlight that improving healthcare access for displaced populations requires multidimensional interventions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. First, reducing financial barriers remains essential. Targeted fee exemptions, transportation subsidies, or emergency risk-pooling mechanisms may mitigate economic constraints [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Second, organizational improvements\u0026mdash;such as reducing waiting times and strengthening medication supply chains\u0026mdash;could significantly enhance effective access without requiring major infrastructural expansion [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Third, respectful communication and anti-discrimination training for healthcare staff should be prioritized. Relational quality is not peripheral but central to engagement [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Fourth, interventions leveraging community leaders and social networks should be carefully designed to avoid reinforcing internal inequalities. Ultimately, policies must recognize that healthcare access in displacement is embedded within broader structural vulnerability and insecurity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. It draws on diverse stakeholder perspectives, enabling triangulation across user and provider experiences. The use of a well-established conceptual framework supports analytical coherence, while the thematic approach allowed identification of context-specific dimensions. However, limitations must be acknowledged. The study was conducted in a single district, which may limit transferability to other conflict settings. Social desirability bias may have influenced participant responses, particularly among professionals. Additionally, as a qualitative study, findings cannot establish prevalence or statistical association. Despite these limitations, the study provides a nuanced and contextually grounded understanding of healthcare access in protracted displacement.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that healthcare access in protracted displacement is a layered, socially mediated process rather than a mere function of service availability. Among IDPs in the Dori health district, effective access is shaped by the convergence of economic precarity, institutional fragility, and relational trust. Displaced individuals must navigate complex trade-offs between financial risk, security constraints, and household survival, making the decision to seek care a socially embedded act rather than a purely biomedical one. The findings highlight that affordability, acceptability, and accessibility interact sequentially in fragile environments, where dignity and institutional legitimacy are central to health system engagement. These insights suggest that health systems in conflict-affected regions must move beyond simple service restoration toward multidimensional strategies that integrate economic protection with high-quality, relational care. Ultimately, achieving equitable health coverage in the Sahel requires a fundamental recognition of the lived realities and ongoing negotiations of displaced populations within uncertain and unequal environments.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e All methods in this study were performed in accordance with the Declaration of Helsinki. The study protocol and all related data collection and consent tools were reviewed and approved by the Comit\u0026eacute; d\u0026rsquo;\u0026Eacute;thique pour la Recherche en Sant\u0026eacute; (CERS), which is the national ethics committee under the Ministry of Health and the Ministry of Higher Education, Research and Innovation of Burkina Faso (Protocol No. 2021-12-292, dated December 01, 2021). Administrative authorization was granted by the regional and district health authorities of the Sahel. Prior to enrollment, the objectives and procedures of the study were explained to all participants in their local language where necessary. Informed consent was obtained from all participants involved in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. All costs associated with data collection and analysis were covered by the authors. The authors declare that no external funders were involved in the study design, data collection, analysis, or the decision to submit the paper for publication.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAKS and PN contributed to the conception and design of the study. AKS conducted the literature review, managed the data, and performed the primary analysis. The interpretation of the results was carried out by AKS and PN. PN drafted the initial manuscript, and both AKS and PN were involved in the review, editing, and supervision of the final article. All authors have read and approved the final version for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank all the study participants who shared their experiences despite the challenging security context. We also extend our gratitude to the health and social service administrators in the Dori health district and the provincial humanitarian coordinators for their administrative support and assistance during the recruitment process.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to the sensitive nature of the data involving vulnerable populations in a conflict-affected region and the need to ensure participant confidentiality. However, anonymized data may be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArage MW et al. Exploring the health consequences of armed conflict: the perspective of Northeast Ethiopia, 2022: a qualitative study. 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Health system strengthening in fragile and conflict-affected states: A review of systematic reviews. PLoS ONE. 2024;19(6):e0305234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoutchi M, et al. Health transformation toward universal healthcare coverage amidst conflict: examining the impact of international cooperation in Niger. Front Public Health. 2024;12:1303168.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeltham E, Forastiere L, Christakis NA. Cognitive representations of social networks in isolated villages. Nat Hum Behav. 2025;9(8):1737\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUe* I, Precious FK, Igwe SC, Uduak JB, Niji-Olawepo T. Enhancing Healthcare Access in Conflict Zones: Identifying Challenges and Proposing Solutions. Public Health Open Access, 2024. 8(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLerosier T et al. Minimal resilience and insurgent conflict: qualitative analysis of the resilience process in six primary health centres in central Mali. BMJ Glob Health, 2023. 7(Suppl 9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOuedraogo O, et al. Landscape analysis of healthcare workforce and resilience actions in the Sahelian context of high security challenge areas: The case of Burkina Faso. Int J Health Plann Manag. 2024;39(3):933\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePitkin Derose K, Varda DM. Social Capital and Health Care Access: A Systematic Review. Med Care Res Rev. 2009;66(3):272\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIqbal P. Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches. Health Expect. 2022;25(5):2065\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank. Health Services for Displaced Populations: Big Questions in Protracted Crises. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoumans JVF, Wark S. A scoping review on the barriers to and facilitators of health services utilisation related to refugee settlement in regional or rural areas of the host country. BMC Public Health. 2024;24(1):199.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIRC (International Rescue Committee). Equitable Access to Health Services: Lessons for Integrating Displaced Populations into National Health Systems. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThartori V, Ismail NAH. Albania and Kosovo-Albania Immigrants' Perceptions of Mental Well-Being and the Psychological Challenges Faced in Malaysia. J Migration Health. 2024;10:100234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammed R, Neuner F. 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Confl Health. 2022;16(1):58.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Internally displaced persons, healthcare access, Levesque framework, Burkina Faso","lastPublishedDoi":"10.21203/rs.3.rs-9132478/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9132478/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealthcare access in conflict-affected settings is frequently examined through structural indicators such as service availability and cost. However, less is known about how displaced populations experience and negotiate access in their daily lives. This qualitative study explores how internally displaced persons (IDPs) in the Dori health district of Burkina Faso navigate healthcare access in a context of protracted insecurity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eForty semi-structured interviews were conducted with IDP leaders, healthcare providers, managers, and NGO representatives. Data were analyzed using thematic analysis guided by the Levesque conceptual framework of access to healthcare. The study involved 40 participants comprising a balanced representation (25% each) of IDP leaders, healthcare providers, health system managers, and NGO representatives. Among the professional participants, 60% possessed over five years of experience in conflict-affected health service delivery or coordination.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFindings reveal that healthcare access operates as a negotiated and sequential process shaped by economic precarity, institutional trust, perceived discrimination, and ongoing insecurity. Participants described weighing financial costs, security risks, and anticipated treatment experiences before seeking care. Social networks functioned as informal infrastructures compensating for institutional fragility, yet potentially reproducing inequalities. Experiences of disrespect and marginalization undermined engagement, highlighting the centrality of dignity within the acceptability dimension of access.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study contributes to theoretical debates by proposing a temporally layered understanding of access in fragile contexts, where structural and relational barriers accumulate cumulatively. These findings call for refined conceptualizations of healthcare access that account for social identity, moral economy, and institutional legitimacy in humanitarian settings.\u003c/p\u003e","manuscriptTitle":"Navigating Healthcare in Displacement: A Qualitative Study of Internally Displaced Persons in Conflict-Affected Burkina Faso","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 18:44:25","doi":"10.21203/rs.3.rs-9132478/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T03:36:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83076862372680402348152026143905942375","date":"2026-04-28T04:28:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303508375476185469678572390950164676891","date":"2026-04-28T02:20:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-26T12:24:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51106607411538313660768344413659869008","date":"2026-04-17T07:08:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138574470103345965896605380235707733014","date":"2026-04-16T07:33:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T09:30:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T16:51:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-20T16:51:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T15:20:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-19T14:16:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cbc996e-1b4a-4303-a93e-d515c076fec7","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T03:36:46+00:00","index":82,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T18:44:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 18:44:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9132478","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9132478","identity":"rs-9132478","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}