The research, published in SSM – Population Health, was led by Hanyul Lee and colleagues, who applied an analytical framework known as MAIHDA—Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy—to a question that has long resisted conventional methods. Unmet medical need, or UMN, refers to situations in which people perceive a need for healthcare but cannot obtain appropriate or sufficient care. Previous studies have typically treated UMN as a single aggregate outcome, or examined risk factors one at a time using standard regression. The problem, the authors argue, is that additive approaches cannot capture what intersectionality theorists have described since Kimberlé Crenshaw’s foundational work: social categories do not simply stack. A woman with a parental role does not experience the sum of ‘female disadvantage’ plus ‘parental disadvantage.’ The intersection generates a qualitatively distinct experience that cannot be reconstructed from its component parts.

MAIHDA addresses this by treating each combination of social characteristics—144 unique strata in this study—as a group in a multilevel logistic regression model, with individuals nested within strata. The method models strata as random effects, which stabilizes estimates even for small groups through statistical shrinkage, a major advantage over stratified analyses that lose power or interaction-term models that become uninterpretable as axes multiply. The researchers fitted two models for each outcome: a null model capturing total between-stratum variation, and a main-effect model adding the average associations of each axis. The difference between the two reveals whether social positions interact in ways that additive averages cannot explain. The team also disaggregated UMN by cause, separating time-related barriers—such as inconvenient clinic hours, inability to leave work, or lack of childcare—from cost-related barriers, where the expense of care itself is prohibitive.

The main effects told a story of two different barriers. For time-related UMN, age, sex, and employment dominated: younger adults had more than three times the odds of older adults, women had 58 percent higher odds than men, and employed individuals had roughly three times the odds of those not employed. Living with children also raised the odds. For cost-related UMN, the picture inverted. Income was the decisive factor—the lowest-income group had more than four and a half times the odds of the highest—and living alone nearly quadrupled the odds. Employment, meanwhile, was protective: employed people had 45 percent lower odds of cost-related UMN than those not employed. Sex and age showed no significant association with cost-related barriers at all. The same social variable, in other words, can push in opposite directions depending on which barrier to care is being measured.

The variance decomposition underscored why disaggregation matters. Intersectional strata explained 18.6 percent of the variation in time-related UMN and 27.3 percent in cost-related UMN in the null models, but only 4.8 percent for overall UMN. When causes are collapsed into a single outcome, effects associated with different barriers partially offset one another, masking the true extent of social patterning. The authors note that even 4.8 percent is not trivial by MAIHDA standards, where values below five percent are common, particularly given that no health-condition variables were included. Discriminatory accuracy followed the same gradient: the area under the receiver operating characteristic curve reached 0.80 for cost-related UMN, compared with 0.60 for overall UMN, meaning that cause-specific models identify high-risk individuals far more effectively.

After accounting for average additive effects, the residual variation attributable to intersectional interaction effects shrank substantially—the proportional change in variance exceeded 80 percent for all outcomes. But the residual effects, though small in aggregate, were concentrated in a handful of strata that proved to be the study’s most revealing finding. For time-related UMN, the three highest interaction effects all belonged to a single social location: younger women who were not employed and living with children. Their interaction effects reached odds ratios of 2.10, 2.06, and 1.59 across the middle-, lowest-, and highest-income tertiles respectively. These women’s predicted probabilities of time-related UMN were comparable to those of employed young adults—an anomaly, since non-employment would ordinarily be expected to free up time. No comparable pattern appeared among non-employed young men.

The authors offer a plausible explanation rooted in the sociology of care. The ideology of intensive mothering prescribes continuous maternal availability and prioritization of children’s needs, which may render non-employment not as relief from time pressure but as an expectation of full-time caregiving. Under such norms, mothers who prioritize their own health needs can experience guilt, leading to deferred care. The pattern is consistent with stark gender asymmetries in unpaid labor: in South Korea, non-employed women in single-earner households with children spend roughly seven hours per day on unpaid household work, about double the time of non-employed men in the reverse configuration. International evidence similarly shows that male unemployment does not translate into equivalent increases in men’s unpaid care work. Gendered role expectations, in other words, operate in both directions—directing women toward child-centered domestic routines while discouraging men from assuming caregiving responsibilities.

For cost-related UMN, the most deviant strata told an unexpected story about men. The highest interaction effect of all belonged to middle-aged men who were not employed and living alone in the highest-income tertile—an odds ratio of 2.60, despite their objective affluence. Two other middle-aged male strata living alone, one non-employed and low-income and one employed and low-income, ranked among the top four. The authors suggest that cost-related unmet need in this group may reflect perceived affordability or the prioritization of healthcare spending rather than genuine financial constraint. Gendered divisions of household labor have historically positioned women as managers of family health, monitoring symptoms and facilitating medical visits; men without a co-residing partner may be less likely to act on health needs at all. In South Korea, where breadwinner norms are particularly strong, non-employment in midlife may also represent a disruptive role failure that further deprioritizes healthcare spending.

The policy implications are pointed. Interventions targeting formal workplaces—flexible hours, sick leave—would reach employed adults but miss the non-employed young mothers whose time-related unmet need was among the highest of any group. Conversely, means-tested subsidies for healthcare costs would capture low-income households but overlook affluent middle-aged men living alone who forgo care for reasons that may be social and psychological rather than financial. The authors caution that their study is cross-sectional and descriptive, that respondents could report only one reason for unmet need, and that binary sex categories cannot fully capture gender diversity. Yet the sensitivity analyses—adjusting for hypertension and diabetes, and excluding those with no perceived need—left the key findings intact. The broader message is that equitable access under universal coverage requires attention not only to entitlement and affordability, but to the gendered organization of work, care, and household responsibility that determines who, in practice, can walk through the clinic door.

Subject of Research: Intersectional gendered disparities in cause-specific unmet medical need in South Korea

Article Title: Gendered experiences of cause-specific unmet medical need: An intersectional analysis using MAIHDA

Article References: Lee, H., Choi, W., Lee, W., & Kim, H. (2026). Gendered experiences of cause-specific unmet medical need: An intersectional analysis using MAIHDA. SSM – Population Health, Article 101980. https://doi.org/10.1016/j.ssmph.2026.101980

Image Credits: AI Generated

DOI: 10.1016/j.ssmph.2026.101980

Keywords: unmet medical need, intersectionality, MAIHDA, gender inequality, South Korea, universal health coverage, healthcare access, time poverty, caregiving, household composition, health equity, multilevel analysis

The research team, led by Celestin Ndikumana of the Department of Governance and Public Administration at the University of Rwanda, together with Emmanuel Shema, Vedaste Ndizera and Gerard Bikorimana, set out to identify the self-reported determinants of subjective wellbeing among these long-standing residents. Subjective wellbeing, in the language of social science, refers to how people evaluate their own lives—their satisfaction with income, health, relationships, housing and daily circumstances—rather than relying on objective measures such as income brackets or infrastructure counts alone. It is a measure that captures something statistics on GDP per capita or housing supply cannot: whether people feel their lives are going well. In rapidly suburbanizing contexts, where formal planning often lags behind informal settlement growth, that subjective dimension may be the most honest barometer of whether urban transition is improving or eroding quality of life.

Methodologically, the study took a deliberately quantitative approach. The researchers collected data from 317 respondents who had directly experienced the conversion of their rural surroundings into a suburbanized environment. Rather than relying on simple averages or descriptive statistics, the team applied a battery of bivariate analyses—including Mann–Whitney tests, Kendall’s tau-b correlations and Kruskal–Wallis tests—to explore how wellbeing differed across demographic and socioeconomic groups. These non-parametric techniques are well suited to ordinal survey data, where respondents rate satisfaction on ordered scales rather than continuous measures. To move beyond association and isolate the factors that genuinely predict life satisfaction, the researchers then estimated an ordered logistic regression model, a statistical framework designed for outcomes that fall into ranked categories. This layered analytical design allowed the team to distinguish, for example, whether marital status mattered for happiness independently of income, or whether household composition exerted its own effect once economic variables were controlled.

The findings complicate a common assumption that marriage and family life universally buffer people against hardship. In this suburbanizing setting, single individuals reported higher odds of being satisfied with their wellbeing compared to their married, separated and widowed counterparts. The authors suggest that this may reflect the economic and social pressures that marital responsibilities impose in transitional environments—pressures that can intensify when land values shift, livelihoods are disrupted and the cost of urban living rises around long-term residents. Separated and widowed respondents faced particular disadvantages, underscoring how marital disruption interacts with urbanization to shape emotional and material security. At the same time, household composition told a more nuanced story: people living together with their spouses and children exhibited higher life satisfaction than those in other living arrangements. The apparent paradox—that being single predicted satisfaction while co-residence with spouse and children also predicted satisfaction—points to the importance of household functioning and support rather than marital status alone, a distinction the researchers argue deserves closer attention in future wellbeing research.

Economic factors emerged as some of the most powerful predictors of life satisfaction in the study. Employment opportunities, income satisfaction and expenditure satisfaction all positively influenced wellbeing, confirming that in suburbanizing areas the transition is experienced largely through the wallet. When farmland disappears, original settlers lose not only agricultural income but also a traditional safety net; their economic fate increasingly depends on access to wage employment, small enterprise or rental income from subdivided land. Respondents who felt their income was adequate and who were satisfied with how their spending covered household needs reported markedly better wellbeing than those who struggled financially. This pattern aligns with broader development literature showing that perceived economic security—rather than absolute income alone—drives subjective evaluations of life. For policymakers, the implication is sharp: urban expansion that generates construction and land speculation but not stable livelihoods for original residents may expand the city’s footprint while shrinking its long-standing communities’ sense of wellbeing.

Beyond economics, the conditions of daily life carried substantial weight. Housing conditions, general health, education and work-life balance all contributed significantly to life satisfaction in the study’s regression model. In suburbanizing peripheries, housing is often the most visible battleground of urban transition: original settlers may see their homesteads crowded by new developments, face pressure to sell or subdivide, or live in structures that no longer match the changing character of the neighborhood. Those with adequate, stable housing reported greater satisfaction, as did those in better general health—an intuitive but important finding, since health systems on urban fringes often fail to keep pace with population growth. Education functioned as both an economic and psychological resource, equipping residents to navigate new opportunities, while work-life balance emerged as a distinct dimension of wellbeing, suggesting that the demands of adapting to a suburbanizing economy can strain time and energy in ways that directly erode life satisfaction.

The study’s geographic and social context matters. Sub-Saharan Africa is urbanizing faster than almost any other world region, and much of that growth is absorbed not by dense city cores but by sprawling peripheral areas where rural land is incrementally converted to urban use. The people who experience this transformation most intimately are original settlers—farmers, herders and villagers who never chose to become urbanites but woke up one day to find the city at their doorstep. Their subjective wellbeing has been chronically under-researched, with most urban wellbeing studies focusing on established city dwellers or rural populations in isolation. By centering original settlers, this study fills a genuine gap and gives a statistical voice to a population often treated as background in narratives of African urban growth. The research was conducted under a postdoctoral fellowship supported by the bilateral cooperation between the University of Rwanda and the Swedish Programme for Research in Higher Education and Institutional Advancement, with guidance acknowledged from Sofie Hellberg of the University of Gothenburg.

Ethical rigor underpinned the data collection. Approval was granted by the Ethics Committee of the University of Rwanda’s Institutional Review Board under protocol 01/CASS-DRI/2023, and the study followed the Declaration of Helsinki guidelines. Informed consent was obtained from all individual participants before data collection, participation was voluntary and confidentiality was assured. These safeguards are particularly important in research on land and livelihoods, where questions about income, housing and family circumstances can touch on sensitive issues of displacement, land sales and economic vulnerability. The authors declare no competing interests relevant to the content of the article, and the work is published open access under a Creative Commons license, making the full dataset of findings available to researchers and policymakers across the region.

What makes the findings resonant beyond a single urban fringe is their consistency with a growing global recognition that wellbeing is multidimensional. Money matters, but so do the people in the household, the roof over one’s head, one’s health, education and the balance between work and the rest of life. In suburbanizing Sub-Saharan Africa, where millions of people are undergoing this transition simultaneously, the study suggests that subjective wellbeing is shaped by the interaction of socioeconomic stability, social relationships and access to opportunities—three pillars that can either reinforce each other or collapse together depending on how the transition is managed. The single-versus-married finding, in particular, invites deeper investigation into how family obligations mediate the stresses of urbanization, and whether support systems for married and widowed residents could close the satisfaction gap the data reveal.

For policymakers, the study distills into a clear agenda: address economic disparities by broadening employment opportunities for original settlers, improve housing conditions as neighborhoods densify, and foster community support systems that sustain the social fabric through the turbulence of transformation. The authors emphasize that enhancing urban quality of life requires looking not only at newcomers and city cores but at the people whom urbanization arrived to meet. As African cities continue their outward march, the happiness of those who were there first may prove one of the most meaningful measures of whether growth is truly development—or merely expansion.

Subject of Research: Determinants of subjective wellbeing among original settlers in rapidly suburbanizing areas on the outskirts of a major city in Sub-Saharan Africa

Article Title: Subjective wellbeing of original settlers in suburbanizing areas on the outskirts of a major city in Sub-Saharan Africa

Article References: Ndikumana, C., Shema, E., Ndizera, V., & Bikorimana, G. (2026). Subjective wellbeing of original settlers in suburbanizing areas on the outskirts of a major city in Sub-Saharan Africa. Discover Social Science and Health. https://doi.org/10.1007/s44155-026-00471-x

Image Credits: AI Generated

DOI: 10.1007/s44155-026-00471-x

Keywords: subjective wellbeing, urbanization, life satisfaction, Sub-Saharan Africa, socioeconomic factors, suburbanization, housing conditions, employment, ordered logistic regression, original settlers, household composition, urban quality of life