Rural health inequalities in perceived HIV vulnerability and nutritional status: a cross-comparison of rural communities in West and Southern Africa

Persistent rural health inequities across Sub-Saharan Africa, particularly regarding HIV burden and nutritional deficiencies, remain a major public health concern, yet evidence indicates that rural disadvantage is neither uniform nor neutral. Anchored in the social determinants of health framework, this study compared household income, healthcare access, and housing quality/sanitation between rural populations in West and Southern Africa; examined cross-national differences in perceived HIV burden and nutritional deficiency; and assessed how these determinants relate to both outcomes. We analysed primary cross-sectional survey data from stratified samples in Ntabankulu villages, South Africa (n = 288) and Iwo villages, Nigeria (n = 205). Cross-country differences were tested using independent-samples t-tests, and associations were estimated using country-stratified multivariable OLS regressions mutually adjusting for income, healthcare access, and housing quality/sanitation. Results show clear contrasts: South Africa reports higher perceived income and better housing/sanitation, whereas Nigeria reports better perceived healthcare access; however, South Africa records higher perceived HIV burden and nutritional deficiency. In adjusted models, income (β = - 0.384) and healthcare access (β = - 0.196) were associated with lower perceived HIV burden in South Africa, while housing quality/sanitation (β = - 0.338) was associated with lower perceived HIV burden in Nigeria. For nutritional deficiency, income was the strongest predictor in South Africa (β = - 0.383), whereas healthcare access (β = - 0.344) and income (β = - 0.246) were significant in Nigeria. These findings suggest that rural health inequalities are structurally driven and context-dependent, stressing the need for country-specific (rather than uniform) policy responses.