Primary healthcare is established to ensure that people have access to health services through facilities located in their community. However, utilisation of health facilities in Nigeria remains low in many communities.
To assess the utilisation of community-based health facility (CBHF) amongst adults in Ibadan, Nigeria
A low-income community in Ibadan North West Local Government Area of Oyo State.
A cross-sectional survey was conducted using a simple random sampling technique to select one adult per household in all 586 houses in the community. A semi-structured interviewer-administered questionnaire was used to collect information on respondents' sociodemographic characteristics, knowledge and utilisation of the CBHF. Data analysis included descriptive statistics and association testing using the Chi-square test at
The mean age of the respondents was 46.5 ± 16.0 years; 46.0% were men and 81.0% married; 26% had no formal education and 38.0% had secondary-level education and above; traders constituted 52.0% of the sample; and 85.2% were of low socioeconomic standing; 90% had patronised the CBHF. The main reasons for non-utilisation were preference for general hospitals (13.8%) and self-medication (12.1%). Respondents who had secondary education and above, were in a higher socioeconomic class, who had good knowledge of the facility and were satisfied with care, utilised the CBHF three months significantly more than their counterparts prior to the study (
The utilisation of the CBHF amongst adults in the study setting is high, driven mostly by satisfaction with the care received previously. Self-medication, promoted by uncontrolled access to drugs through pharmacies and patent medicine stores, threatens this high utilisation.
Les soins de santé primaire ont été établis pour permettre aux gens d'avoir accès aux services de santé dans des établissements installés dans leur communauté. Cependant, l'utilisation des équipements sanitaires au Nigeria est faible dans de nombreuses communautés.
Evaluer l'utilisation d'un établissement communautaire de santé (CBHF) par les adultes à Ibadan, Nigeria
Une communauté à faibles revenues dans la Zone de Gouvernement local d'Ibadan Nord Ouest (IBNWLGA) de l'état d'Oyo.
On a effectué une enquête transversale au moyen d'une technique d' échantillonnage simple au hasard pour sélectionner un adulte par ménage dans les 586 maisons de la communauté. On s'est servi d'un questionnaire semi-structuré administré par l'interviewer pour collecter les informations sur les caractéristiques sociodémographiques, les connaissances et l'utilisation du CBHF par les personnes interrogées. L'analyse des données comprenait des statistiques descriptives et des tests d'association au moyen du test de Chi-carré à
L'âge moyen des personnes interrogées était de 46.5 ± 16.0 ans; 46.0% étaient des hommes et 81.0% étaient mariés. Vingt-six pour cent n'avaient pas d'éducation formelle; et 38.0% avaient fait des études secondaires et plus. Les commerçants constituaient 52.0% de l'échantillon; et 85.2% avaient un statut socioéconomique modeste. Quatre-vingt-dix pour cent avaient fréquenté le CBHF. Les raisons principales pour la non utilisation de l'établissement étaient une préférence pour les hôpitaux généraux (13.8%) et l'automédication (12.1%). Les personnes interrogées qui avaient fait des études secondaires et plus, appartenaient à une classe sociale supérieure; ils connaissaient bien l'établissement et étaient satisfaits des soins, et ils avaient considérablement utilisé le CBHF trois mois avant l'enquête par rapport à leurs homologues (
L'utilisation du CBHF par les adultes de l'étude est élevée, et liée essentiellement à la satisfaction des soins reçus au paravent. L'automédication, encouragée par l'accès incontrôlé aux médicaments des pharmacies et des magasins qui vendent des médicaments brevetés, menace l'utilisation élevée de l'établissement.
Primary healthcare (PHC) is defined as:
essential healthcare based on practical, scientifically-sound and socially-acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them at a cost that the community and country can afford to maintain at every stage of their development in a spirit of self-reliance and self-determination.
It forms an integral part of both the countries' health system of which it is the central function and the main focus of the overall social and economic development of the community. It is also the first level of contact of individuals, families and communities with the national health system, bringing healthcare as close as possible to where people live and work and constitutes the first element of continuing health care process.
Emphasis in healthcare has changed from healthcare
The inception of PHC has facilitated some communities to have at least one health care facility sited as close as possible to where they live or work in all the districts or local government areas of many of the states in Nigeria. However, siting of health care facility does not necessarily translate to its utilisation; more so, that one of the major factors maintaining high mortality rate in Nigeria is poor access to and utilisation of health services.
Primary healthcare is established to ensure that people have access to health services through health facilities located in their community. However, utilisation of health facilities in Nigeria remains unacceptably low in many communities. A household survey amongst 630 respondents in Northern Nigeria showed that the majority preferred to use patent medicine stores (53.63%) compared with only 7.6% who utilised the PHC services.
Studies on health services utilisation often seek to understand both the frequency and trends in the use of health services, as well as the possible mechanisms that may be associated with the pattern of use.
Given that the utilisation of the CBHF by the community members at Idikan, Ibadan, Nigeria has hitherto not been assessed since its advent, the current study aimed to assess the utilisation of the facility within the three months preceding the study and to identify reasons for any lack of utilisation. It is hoped that the findings of this study will inform interventions for the improvement of PHC services in the community, hence the need for this study. Achieving this will enable better decisions to be made, which should result in better, more effective primary care for the people of the area in the long run. Therefore, the objective of this study was to assess the utilisation of the facility within the three months preceding the interview as well as to assess any reasons for any lack of utilisation of the facility, so that these can be corrected, if possible, for the improvement of PHC in the area.
This was a community-based descriptive cross-sectional survey.
The study was conducted in Idikan, a low-income urban community located in Ibadan North West Local Government Area of Oyo State, South-western Nigeria. The community has an estimated population of 13 902 based on the 2006 population census.
The study population consisted of male and female adults residing in selected households.
The sample size was calculated using Leslie Kish's formula for descriptive surveys.
There were a total of 586 houses in Idikan community with an average of 3–4 households per dwelling. All 586 houses were visited. In places where there were more than one household per house, one household was selected randomly by balloting. In the selected household, one adult was selected by a simple random sampling technique by balloting.
The study was conducted using a semi-structured interviewer-administered questionnaire. Five research assistants were recruited from the community and trained in order to administer the questionnaire. The interview was conducted mostly in the evening, which is when most of the community members were around. The questionnaire covered: sociodemographic characteristics; perception of community health services by adult members in the community; pattern of presentation in the three months preceding the interview; the utilisation of the CBHF for common illnesses in the three months preceding the interview; and obstacles against use of the community health services.
The questionnaire was standardised after it had been critiqued during a departmental proposal presentation with consultants, senior registrars and registrars present. Through constructive criticism, any possible shortcomings which could affect the quality and feasibility of the study were identified and rectified. The questionnaire was translated into Yoruba for the benefit of the majority who were predominantly Yoruba speaking, then translated back to formal English by a different translator from the first to ensure that there was no error in translation and that the original meaning was retained.
Pretesting was carried out on 15 subjects in Abebi, an adjoining community in the area which was not part of the study area but has similar characteristics. The pre-test was found necessary in order to ensure clarity of interpretation, ease of completion, reduce respondents' bias and generate useful questions not initially conceived but very germane to the quality of the study and to correct any ambiguity whatsoever detected. Corrections and relevant restructuring were made in places of ambiguity.
The data obtained were sorted out, edited and manually cleaned and recoded where necessary. Data were entered into the computer and analysed with SPSS software v 16.0 (SPSS Inc., Chicago, IL 2007). Data analysis was done with the assistance of a statistician using both descriptive and inferential statistics. Descriptive statistics such as percentages or proportions were used to describe the qualitative or categorical variables. The Chi-square test was used to examine the relationship between two categorical variables. The test was carried out at 5% level of significance.
Responses to questions on knowledge of the CBHF were converted to a 40-point score by coding a correct answer as ‘1' and a wrong answer as ‘0'. The knowledge scores were generated giving minimum and maximum obtainable scores of 0 and 40 respectively. Respondents were categorised into having good, fair and poor knowledge using 75% and above, 50% – 74% and 49% and below of the maximum obtainable scores, respectively. Seventy-five per cent was used as the lowest limit for good knowledge because the CBHF had been in Idikan community for more than two decades before this assessment. It was located both centrally and within 1 km of all the community members for easy accessibility. Hence, respondents with a knowledge score of 30 and above were reported as having good knowledge, fair (20–29) and poor (< 20). Similarly, responses to perception questions were converted to a 60-point score. Perception scores were generated with minimum and maximum obtainable scores of 12 and 60 respectively. Respondents were classified into having poor, fair and good perception of some characteristics of the CBHF using 75% and above, 50% – 74% and 49% and below of the total obtainable scores, respectively. Hence, those with scores of 36 or less were regarded as having poor perception, 37–49 fair and ≥ 50 good perception. Satisfaction with the services at the CBHF was assessed by asking if respondents were satisfied with the services received at the facility, generating a ‘yes' or ‘no' response.
Multivariate analysis using binary logistic regression
The occupation of respondents was classified into high and low occupational class for ease of bivariate analysis, in some instances by modifying the social class based on occupation alone, as adopted from Rose and Pevalin (2001).
Ethical approval was obtained from Oyo State Ethical Review Committee, State Ministry of Health (reference number AD/13/479/146). Permission and cooperation were sought from the High Chief of Idikan Community. Verbal informed consent was also ensured from all the participants. No names were recorded on the questionnaire so as to ensure confidentiality; and codes were used for identification of respondents instead of names.
A total of 586 households were visited, from which 554 respondents consented – a response rate of 95%. The respondents' sociodemographic characteristics are shown in
Sociodemographic characteristics of respondents.
Variables ( |
Frequency | Percentage |
---|---|---|
Male | 254 | 46 |
Female | 300 | 54 |
< 20 | 4 | 0.7 |
20–29 | 78 | 14.1 |
30–39 | 121 | 21.8 |
40–49 | 116 | 20.8 |
50–59 | 87 | 15.7 |
60–69 | 74 | 13.4 |
> 70 | 57 | 10.3 |
No response | 17 | 3.1 |
Yoruba | 507 | 91.5 |
Igbo | 43 | 7.8 |
Hausa | 4 | 0.7 |
Single | 29 | 5.2 |
Married | 447 | 80.7 |
Separated | 13 | 2.3 |
Divorced | 13 | 2.3 |
Widowed | 52 | 9.4 |
Islam | 347 | 62.6 |
Christianity | 205 | 37 |
Traditional | 2 | 0.4 |
Monogamous | 352 | 63.5 |
Polygamous | 202 | 36.5 |
No formal education | 143 | 25.8 |
Quranic | 49 | 8.8 |
Primary | 153 | 27.6 |
Secondary | 173 | 31.2 |
Tertiary | 36 | 6.5 |
Professional† | 24 | 4.3 |
Civil servant | 25 | 4.5 |
Artisan | 90 | 16.2 |
Trading | 289 | 52.2 |
Unemployed | 56 | 10.1 |
Other‡ | 70 | 12.6 |
< 5000 | 241 | 43.5 |
5000–9999 | 79 | 14.3 |
> 10 000 | 124 | 22.3 |
No response | 110 | 19.9 |
Low (1–5) | 472 | 85.2 |
High (6–9) | 82 | 14.8 |
≤ 5 km | 434 | 78.3 |
> 5 km | 120 | 21.7 |
†, Engineers, teachers; ‡, Clergy, students, drivers, farmers.
The majority (
Distribution of respondents regarding knowledge of the community-based health facility.
Knowledge areas ( |
Correct |
Incorrect |
---|---|---|
373 (75.2) | 123 (24.8) | |
Antenatal care | 327 (65.9) | 169 (34.1) |
Immunisation | 378 (68.2) | 118 (23.8) |
Family planning | 454 (91.5) | 42 (8.5) |
Treatment of common ailments | 389 (78.4) | 107 (21.6) |
Health education | 285 (57.5) | 211 (42.5) |
Referral | 313 (61.3) | 183 (36.9) |
Ultra Sound Scan | 298 (60.1) | 198 (39.9) |
Free | 336 (67.7) | 160 (32.3) |
24 hours | 361 (72.8) | 135 (27.2) |
310 (62.5) | 186 (37.5) | |
236 (47.6) | 260 (52.4) | |
Good (30 and above) | 284 | 57.3 |
Fair (20-29) | 116 | 23.4 |
Poor (19 and below) | 96 | 19.3 |
Most the respondents (
Percentage distribution of respondents by reasons for utilising the community-based health facility.
Amongst those that sought medical care outside the home in the three months preceding the interview, 212 (93.8%) specified their sources of care. One hundred and fifty-one respondents (66.8%) reported the CBHF as their source of medical care three months prior to interview, 34 (15.0%) a private hospital, 16 (7.1%) government-owned hospitals and 11 (4.9%) a faith-based organisation.
Results of the bivariate analysis are shown in
Association between utilisation of services at the community-based health facility for three months before survey and respondents' characteristics.
Variables | Received treatment in last 3 months | |||
---|---|---|---|---|
Yes |
No |
|||
< 30 | 21 (25.6) | 61 (74.4) | 3.938 | 0.140 |
30–59 | 96 (29.6) | 228 (70.4) | ||
60 and above | 27 (20.6) | 104 (79.4) | ||
Male | 72 (28.2) | 183 (71.8) | 0.228 | 0.633 |
Female | 79 (26.4) | 220 (73.6) | ||
High | 18 (43.9) | 23 (56.1) | 6.188 | 0.013* |
Low | 133 (25.9) | 380 (74.1) | ||
No formal | 41 (21.4) | 151 (78.6) | 7.569 | 0.023* |
Primary | 40 (26.1) | 113 (73.9) | ||
Secondary and above | 70 (33.5) | 139 (66.5) | ||
Low | 119 (25.2) | 353 (74.8) | 6.722 | 0.010* |
High | 32 (39.0) | 50 (61.0) | ||
Professional | 13 (43.3) | 17 (56.7) | 5.130 | 0.275 |
Civil servant | 9 (28.1) | 23 (71.9) | ||
Artisan | 24 (23.3) | 79 (76.7) | ||
Traders | 69 (28.0) | 177 (72.0) | ||
Other | 36 (25.2) | 107 (74.8) | ||
Never | 15 (51.7) | 14 (48.3) | 9.24 | 0.002* |
Ever | 136 (25.9) | 389 (74.1) | ||
Yoruba | 139 (27.4) | 368 (72.6) | 0.077 | 0.781 |
Other | 12 (25.5) | 35 (74.5) | ||
Christianity | 62 (30.2) | 143 (69.8) | 1.465 | 0.226 |
Islam | 89 (25.5) | 260 (74.5) | ||
Polygamous | 92 (26.1) | 260 (73.9) | 0.611 | 0.435 |
Monogamous | 59 (29.2) | 143 (70.8) | ||
< 5000 | 71 (31.4) | 157 (68.6) | 1.424 | 0.491 |
5000–9000 | 23 (25.3) | 68 (74.7) | ||
10 000 and above | 34 (27.4) | 90 (72.6) | ||
Yes | 136 (36.9) | 233 (63.1) | 37.948 | <0.001* |
No | 8 (6.9) | 108 (93.1) | ||
≤ 5 | 113 (26.0) | 321 (74.0) | 1.503 | 0.220 |
> 5 | 38 (31.7) | 82 (68.3) | ||
≤ 14 days | 136 (30.8) | 306 (69.2) | 0.001 | 0.982 |
> 14 days | 15 (30.6) | 34 (69.4) | ||
Mild | 104 (31.1) | 230 (68.9) | 0.033 | 0.856 |
Severe | 47 (30.3) | 108 (69.7) | ||
Poor (< 20) | 6 (6.3) | 90 (93.8) | 43.269 | < 0.001* |
Fair (21–29) | 26 (22.4) | 90 (77.6) | ||
Good (30 and above) | 114 (40.1) | 170 (59.9) | ||
Poor | 5 (5.3) | 90 (94.7) | 33.421 | < 0.001* |
Fair | 12 (40.0) | 18 (60.0) | ||
Good | 129 (34.8) | 242 (65.2) |
In the multivariate logistic regression analysis (
Adjusted odds ratio of predictors of utilisation of the community-based health facility.
Variables | Odds ratio | 95% CI | |
---|---|---|---|
High | 1.000 | ||
Low | 0.594 | 0.203–1.737 | 0.342 |
No formal | 1.000 | ||
Primary | 0.904 | 0.520–1.571 | 0.719 |
Secondary | 0.913 | 0.514–1.621 | 0.756 |
Low | 1.000 | ||
High | 1.437 | 0.615–3.353 | 0.402 |
Never | 1.000 | ||
Ever | 0.409 | 0.138–1.213 | 0.107 |
Yes | 1.000 | ||
No | 0.378 | 0.144–0.984 | 0.049* |
Poor | 1.000 | ||
Fair | 0.831 | 0.132–5.249 | 0.844 |
Good | 1.711 | 0.276–10.618 | 0.564 |
Poor | 1.000 | ||
Fair | 4.278 | 0.495–36.982 | 0.187 |
Good | 3.326 | 0.448–24.682 | 0.240 |
This study was carried out to assess the utilisation of the CBHF by adult members in a low-income urban community in Ibadan for the purpose of promoting/optimising and upgrading PHC in the area. The majority of the respondents (89.5%) had utilised the CBHF at one time or the other and utilisation of services in the preceding three months was equally high (89%). Utilisation in the preceding three months was in relation to treatment of injuries and ailments, whether acute or chronic. However, the respondents' awareness of the service components of PHC provided at the CBHF was low. Less than half knew about health education, 36.9% were aware of referral services, followed by antenatal services (34.1%) and immunisation (23.8%). This means that respondents were not aware of the full range of the services provided at the CBHF based on the PHC service components. Utilisation of services in the preceding three months showed that they were more familiar with use of the facility for treatment of disease conditions such as malaria, hypertension and diabetes. The low awareness of the service components of PHC amongst respondents in this study may be a result of poor enlightenment of the public regarding the component services available at the centre with health workers, provision of services for only six hours without admission; non-provision of delivery services, in addition to antenatal care, which would have encouraged patients and relatives to stay for a longer period in the facility and provide opportunities for exposure to the other services being offered at the centre. The poor awareness reported in our study is in contrast to a community-based study in India where awareness of services was high but utilisation was relatively low (54.9%).
The reasons adduced for utilisation of the CBHF were that services were good and readily available, health facility was nearer to their homes, drugs were readily available and attention was prompt. Reasons for non-utilisation in this study included preference for general hospitals, self-medication, private hospitals and traditional healers. In a study to determine utilisation of approved health facilities for delivery in Ile-Ife, the reasons given for non-utilisation of the health facilities at hand were time of onset of labour, problems with transport, fear of surgery, husband and/or family influence and the fact that delivery was assisted by Traditional Birth Attendants (TBAs) and relatives.
The practice of self-medication amongst 12.1% of the respondents is worthy of mention. Considering the fact less than a third reported that the services at the CBHF were not readily accessible may be explained by the fact that services are only accessible in this facility for a maximum of six hours per day. This may force community members to become more dependent on self-medication and traditional healers because drugs are not available at all hours. This automatically makes the services of ‘quacks’ and patent medicine merchants readily available. However, there is also the possibility that their low level of education and strong cultural beliefs could contribute equally to this. However, a survey in Kathmandu, Nepal, showed that individuals turned to modern health sector ‘because they are dissatisfied with the previous folk or traditional professional consultation or because or traditional practitioners had advised them to seek modern hospital services’.
The findings of this research on bivariate analysis indicated that utilisation patterns can be explained, to a large extent, by factors relating to occupational class, socioeconomic status, level of education and level of satisfaction, as well as knowledge of and perception of respondents toward the services. However, it was only the level of satisfaction that was a significant predictor on logistic regression. These findings are consistent with findings from prior research: a bivariate analysis in determinants of utilisation of health services in the western states of Nigeria revealed age, level of education, type of education, place of work and attitudes toward services as being significant factors.
‘The distance patients must travel in order to obtain treatment has long been recognized as a primary determinant of the utilization of health care facilities’.
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The utilisation of the CBHF at Idikan was high but the awareness of the various service components of PHC was low. Higher occupational and socioeconomic status, higher level of education, satisfaction with previous care, good awareness and perception of the CBHF were factors associated with utilisation of CBHF, although only satisfaction with previous care predicted utilisation on logistic regression.
Information on healthcare utilisation has important policy implications in health systems development. Public awareness programmes that mobilise the community to participate in the design and running of the CBHF need to be developed in order to increase awareness and sustain utilisation of the services at the CBHF. Issues surrounding waiting time, availability of drugs and accessibility should also be addressed by the institution in order to sustain the current level of utilisation. The stakeholders should review the hours of service from the current maximum of six hours to 24 hours; this might require scaling up of resources.
The authors would like to acknowledge the contributions of the research assistants, data entry clerk and analyst, the nursing officers at the community-based health facility and the community leaders and members for their cooperation and support.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
A.M.A. (University of Ibadan) was responsible for the conceptualisation of the study, supervision of the process of data collection, entry and analysis; and the writing of the manuscript. M.C.A. (University of Ibadan) was involved in the conceptualisation and supervision of the manuscript writing.