Community perspectives on access to healthcare for the Rama indigenous people, Nicaragua: the utility of Cultural Safety outside high-income countries

Abstract Indigenous Peoples worldwide experience significantly worse health outcomes than people who are non-Indigenous. The challenges they face are generally more severe in low- and middle-income countries, but most research has focused on high-income countries, mainly Australia, Canada, New Zealand and the USA. This study aimed to help redress this imbalance by focusing on access to healthcare for the Rama indigenous people, a community of around 2,000 people who live on the Caribbean Coast of Nicaragua. The data for this study were drawn from face-to-face and online interviews with Rama and non-Rama participants, conducted during two periods: one in spring 2016 and one in January 2024. In total, 49 participants were interviewed, 28 of whom were female. The research found that although government healthcare was nominally free, limited supplies, equipment shortages, and staff constraints pushed many Rama people to rely on expensive private care. This could strain household incomes, which were already under greater pressure than other local, non-indigenous households. Travel to tertiary care centres was costly and difficult because of the distance between Rama communities and where most regional healthcare centres were based. This was one contributory factor that Rama families often took into account when making decisions about when and where to seek healthcare. The language barrier between Rama service users and non-Rama health professionals, perceived discrimination, and non-Rama health professionals’ lack of local knowledge further discouraged care-seeking; and there were many barriers for Rama people who wished to train as health professionals. Although Traditional Medicine was valued, its use declined between 2016 and 2024. Progress towards culturally safe healthcare for the Rama will be difficult; supporting more Rama people to become medically trained and promoting longer-term placements in Rama communities for trained health professionals could help in its achievement.