Auma CMN, Karing'u P, Harriss E, English M, Oliwa J, Okiro EA
Int J Equity Health. 2025;24
INTRODUCTION: Many national development strategies are implemented at the subnational administrative level, serving as critical units for service delivery. Some subnational levels remain underserved and face significant obstacles to achieving equitable development. In Sub-Saharan Africa, underserved regions are often called hardship areas; however, there is no clarity on how such areas are defined across various contexts. Therefore, this scoping review aimed to delineate the definitions of hardship areas across countries in Sub-Saharan Africa and develop a unified typology of their features. METHODS: This scoping review followed the framework by Arksey and O’Malley, aligned with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We searched Ovid Embase, Ovid MEDLINE, CINAHL via EBSCOhost, Ovid Global Health, and Scopus from 1st January 2010 to 8th October 2024, as well as grey literature from websites. We imported the retrieved articles into Covidence. One reviewer conducted the title and abstract screening. For full-text review, one reviewer assessed all the articles, whereas the second reviewer independently evaluated a random sample of 20%, achieving a 90% agreement. Data were systematically extracted, tabulated, and synthesised using deductive and inductive thematic approaches. RESULTS: Of the 15,017 articles screened, 210 articles met the inclusion criteria. Only 137 articles were included, as the remaining 73 provided no new information. We identified several definitions and synthesised them into 79 relatively distinct features. These were grouped into 6 contextual themes: physical/geographical location and accessibility, social services, economic and livelihood challenges, demographic characteristics, security and governance, and natural and man-made disasters, with 16 subthemes. STRENGTHS AND LIMITATIONS: We applied the Arksey and O’Malley framework, which fostered collaborative engagement in developing the research topic and search strategy. Limitations included few primary studies capturing lived experiences, a focus on three AFRHiCARE countries which restricted broader policy comparisons, and omission of non-English publications. CONCLUSION: In Sub-Saharan Africa, hardship is a multidimensional notion with context-dependent features. The typology developed in this review lays the groundwork for geospatial characterisation of hardship, bridges definitional gaps, and supports transparent, effective, and equitable policy responses. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12939-025-02694-x.
