A Critical Examination of the Socio-Structural Determinants of Health Education Access Inequality in Rural Northern Nigeria: A Realist Synthesis

Access inequality in health education across rural northern Nigeria is shaped by intersecting socio-structural determinants that remain inadequately theorised in the public health education literature. This study conducted a realist synthesis to critically examine the socio-structural determinants of health education access inequality in rural northern Nigeria, encompassing the North West and North East geopolitical zones. A three-phase realist synthesis methodology was employed: scoping and theory elucidation, systematic evidence synthesis, and framework refinement. Over 90 peer-reviewed studies, grey literature documents, and policy reports published between 2019 and 2024 were critically appraised. Empirical data supplementing the synthesis were drawn from 36 key informant interviews with health educators, policy makers, and community leaders across Kano, Sokoto, Yobe, and Bauchi states. Synthesis findings identified seven primary socio-structural mechanisms including gender hierarchy, economic marginalisation, educational deprivation, health system underinvestment, geographic remoteness, cultural gatekeeping, and linguistic barriers as configuring contexts that generate health education access inequalities. The study advances a Socio-Structural Health Education Access Model as an original theoretical contribution, providing a realist explanatory account of how context shapes mechanism to produce inequitable outcomes. Policy recommendations include structural reform of community health education delivery systems. Keywords: health education access, inequality, socio-structural determinants, rural northern Nigeria, realist synthesis