Household income and women's reproductive strategies in Almaty (Kazakhstan): Urban stratification of access to health

Ainur Bakytzhanova, Gulzhan Alimbekova

Dialogues in Health, 2026

Full text Open access: Gold Metadata (CSL-JSON)
DOI 10.1016/j.dialog.2026.100355
Data confidence 70 medium
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Abstract

Purpose The aim of this article is to demonstrate how household financial status and the spatial structure of opportunities in the metropolis are interrelated with women's reproductive strategies in Almaty, where formal access to healthcare is combined with uneven access costs in terms of time, money, quality, and predictability of service delivery. Methods The empirical basis consisted of a cross-sectional survey of women of reproductive age in eight districts of Almaty ( N = 934). The analysis utilized a scale reliability assessment (Cronbach's α), χ 2 contingency tables with Cramer's V, and interdistrict comparisons using the nonparametric Kruskal-Wallis test and the median test. The urban environment was operationalized through an infrastructure provision index, comprising six domains: Education, clinics, retail and service environment, leisure, sports, and safety. Results The resulting six-item index demonstrated good internal consistency (Cronbach's α = 0.814; standardized α = 0.815; n = 780). Statistically significant interdistrict heterogeneity was found in accessibility of clinics (χ 2 = 16.048; p = 0.025), retail and service infrastructure (χ 2 = 28.472; p < 0.001), leisure (χ 2 = 32.640; p < 0.001), sports (χ 2 = 31.666; p < 0.001), and safety (χ 2 = 17.801; p = 0.013), while no differences were found in educational infrastructure ( p = 0.844). The most significant predictors of reproductive practices and attitudes were household financial well-being and education level. The results demonstrate that the formal availability of services does not imply equality in actual access to them. Conclusion Inequality in reproductive opportunities is reproduced through hidden transaction costs of access, waiting, transportation logistics, the need for paid alternatives, and additional support resources. Neighborhood of residence is not only a territorial characteristic but also an indicator of the organizational structure of everyday life, influencing care-seeking behavior and family planning strategies. The proposed framework of the Atlas of Reproductive Opportunities can be used to identify local bottlenecks and inform targeted preventive and management decisions.