FACTORS AFFECTING UTILIZATION OF PUBLIC HEALTH FACILITIES BY RURAL DWELLERS IN ABIA STATE

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ABSTRACT
BACKGROUND: Utilization of public health services is an important factor in the effectiveness of national health care and achievement of Health for All. Nigeria’s population is predominantly rural and the health needs of rural areas are numerous. For one to be able to maintain a healthy state, the choice of health care facilities/services and predictors of the choice are important. An individual’s choice of health facilities for healthcare is largely determined by patient-related factors and provider-related factors and these affect patient’s health outcomes. These choices of health care provider may also give an insight into how these health facilities can improve on their service delivery, improve client satisfaction and by extension ensure a healthier population.
OBJECTIVES: To determine factors (both patient-related and provider-related ) affecting the utilization of Public health facilities by rural dwellers in Abia state south east Nigeria. Also to elicit their health related activities and level of satisfaction with Public health facilities.
METHODOLOGY: It was a population based cross-sectional, descriptive study, carried out in selected rural areas of Abia state in south east geopolitical zone of Nigeria. 447 household heads or caregivers adults permanently residing in the selected rural areas were randomly selected and then interviewed using a pretested, semi structured questionnaire. Frequencies, percentages and mean were calculated, tables were created and comparisons of categorical data were done using descriptive methods. Chi square test was used to determine factors that were significant at a p- value of 0.05 and logistic regression was used to determine the predictors for choice of health care facility.
RESULTS: The results indicated that 282 out of 447 0f the rural study population utilized public healthcare facilities. The patient related factors that encourage the utilization of public health facilities included age (31-40yrs), gender (male), marital status (married) and employment status (Government employed)  There were no significant relationship between  educational level, family income, household size and duration of stay in community at p-vales of 0.05.
The provider-related variables influencing the choice of public health facility for respondents included factors like internal organization and procedures, availability of health information, working hours, cost of service, waiting time and availability of ancillary services matters. This study also reported that users of government facilities were just somewhat satisfied with services rendered, location of the facility, overall cleanliness of the center, Staff courtesy and friendliness, skill and competency of the staff the health services they received. They are very satisfied with the efficiency of nursing care and work schedule of care in the clinic.

CONCLUSION: This study highlighted that the utilization of public health facilities by ural-urban dweller in Abia state is high. Choice of health care providing facility is an important decision that involves the interplay of several factors. Understanding these factors by health policy makers is important in the provision and the utilisation of health care services . Also satisfaction with services provided is a perception by the clients and must be considered by managers of health institutions when decisions to improve health facility services are to be made. A healthy population is an asset to any society. Consequently, improving the health-care delivery system in the public setting will in the long run improve the quality of life of the people in the study area.


TABLE OF CONTENTS

Title page
Table of contents
List of figures
List of tables
Abbreviations and Acronyms
Abstract

CHAPTER 1:   INTRODUCTION
1.1       Background
1.2       Statement of problem
1.3       Justification of study
1.4       Relevance to public health
1.5       Aim of study

CHAPTER 2:   LITERATURE REVIEW
2.1                   Overview
2.2                   Factors influencing utilization of public health facilities
2.3                   Nigerian Health system
2.4                   The concept of rural areas

CHAPTER 3:    METHODOLOGY
3.1       Background to the study area
3.2       Study design
3.3       Study population
3.4       Sample size
3.5       Sampling Method
3.6       Survey instrument
3.7       Pretesting of questionnaire and orientation of data collectors
3.8       Data collection
3.9       Data processing and analysis
3.10     Ethical consideration

CHAPTER 4:    RESULTS
4.1       Descriptive analysis of Socio-demographic characteristic/ individual-related factors
4.2       Multivariate analysis individual-related factors affecting utilization of public health facilities by rural dwellers in Abia state
4.3       Health service provider related factors
4.4       Multivariate analysis health service provider-related factors affecting utilization of public health facilities by rural dwellers in Abia state
4.5       The health-related activities of rural dwellers in Abia state
4.6       Level of satisfaction with services of healthcare provider

CHAPTER 5: DISCUSSION
5.1       Study area and health facility utilization pattern
5.2       Socio-demographic characteristics of respondents (Individual related factors: predisposing factors) and public health facility utilization
5.3       Health provider related factors and health facility utilization
5.4       The health-related activities of rural dwellers in Abia state
5.5       Level of satisfaction with services of healthcare provider
5.6       Limitations of the study

CHAPTER 6: CONCLUSION AND RECOMMENDATION
6.1       Conclusion
6.2       Recommendation
REFERENCES
APPENDICES

CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
            The World Health Organization (WHO) is greatly concerned with the provision of quality health care for everyone irrespective of varying levels of living. This implies whether the person is in the advanced or poor countries, rural or urban, poor or rich; good health should be guaranteed by the governments of all countries1. Health as defined by WHO is a state of complete physical, mental, and social well-being and not merely the absence of diseases or infirmity.2 The determinants of health of an individual at any particular time include: the social and economic environment, the physical environment, and the person’s individual characteristics and behaviours3. Illness or diseases is a very common thing that can come at anytime to an individual, when this occur the in-born survival instinct in man will want to fight back at all cost to become well again. Methods engaged to maintain and restore healthy status is described by Health seeking behaviors. Health or care seeking behaviour has been defined as any action undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding appropriate treatment.7 Health services utilization simply means the willingness of the would-be or potential patients to make use  of the most of the services offered at a medical establishment.4The health care utilisation of a population is dependent on their health seeking behaviour which has many determinants: physical, political, socioeconomic and socio-cultural.5
Researchers have long been interested in what facilitates the use of health services, and what influences people to behave differently in relation to their health. Most theoretical models view health care-seeking behavior as a result of rational individual choice.6 Although many of these factors are similar across populations, exactly how they interact and influence the actions of people is often unique to a population in the context of the environment they live in.7
Across the globe, no country can boast of a perfect health system that caters for the need of the whole populace. According to Anderson and Newman, studies on the Analyses of the determinants of medical care utilization in USA are receiving increasing attention because of the emergence of a number of related societal values and perceptions including:
 (1) A growing consensus that all people have a right to medical care regardless of their ability to pay for this care.
 (2) The general belief that certain  disadvantaged population groups such as the “poor,” blacks, Spanish-speaking Americans, American Indians, and inner city and rural residents, are not receiving medical care which is comparable in terms of quality and quantity that is available to the rest of the population.
 (3) High expectations concerning the extent to which medical care can contribute to the general health level of the population.
 (4) Public consternation over “the crisis in medical care” stimulated by rapidly rising prices and growing dissatisfaction about the availability of services.8  
These reasons are not far from the situation in the African continent, Nigeria in this context.
Many low-income countries, Nigeria inclusive, have not been able to meet the basic healthcare needs of their people, especially those in the rural areas.9With a population estimate of more than 170 million, Nigeria is the most populous country in Africa and ranks the 7th in the world. The percentage of the populace residing in the rural area is about 70% . It has an annual population growth rate of 2.83% and the male female ratio is 50.9:49.1.10Nigeria’s overall health system performance was ranked 187th position among the 191 Member States of the World Health Organization in 2000.11 Health status indicators are worse than the average for sub-Saharan Africa. For example, 2013 estimates put life expectancy in Nigeria at 55 years.12 It is assumed that improvement in health leads to improvement in life expectancy, which is a robust indicator of human development13. Improvements in key health indicators have been slow and today Nigeria ranks among the countries with the highest child and maternal mortality: infant mortality rate of 74 deaths per 1,000 live births, the Under-five mortality rate is 117 per 1,000 live births, and the maternal mortality ratio is estimated at 560 per 100,000 live births.14 This is one of the highest in the world.
Nigerian health system includes orthodox, alternative and traditional systems of health care delivery. The Government recognises and regulates these three systems. The health care system in Nigeria accommodates both private and public health care providers. In the public sector health care providers are under the three tiers of government; federal (tertiary hospitals and some hospitals in federal institutions like universities), state (state specialist and general hospitals) and local government areas (primary health care centres and health posts). In the private sector, they are broadly categorized into those that provide primary care (general practitioners), those that provide secondary care and those that provide both primary and specialist care. There are also several non-governmental organizations and donor- owned and operated facilities. 15 Various Nigerian governments have made great efforts toward the provision of healthcare facilities to its populace. Notable among these efforts were the expansion of medical education, improvement of public health care systems, provision of primary health care (PHC) in many rural areas.16
According to the Federal Ministry of Health (2008), the total shares of public ownership in 2004 on health facilities were 14,607 while the private sector accounted for 9,029 in Nigeria. Public and private health care facilities are sparsely provided in many rural areas within the country.1 Moreover, clinics in rural areas often lack adequate equipment or trained health personnel, and require payment before providing services.18 With over 70% of inhabitants in Nigeria residing in rural communities, the overall health indices can only improve if sufficient health facilities/projects are attracted to such areas.
Good health is a need for all and the choice of a particular healthcare system respond to the laws of demand and supply, the demand for health care is a derived demand. Health care is not demanded for itself but for the advantages that can be derived from being healthy.16 This choice has been shown to be limited by factors such as availability, accessibility, affordability of services of the health facilities, cultural beliefs, the situation per time (i.e. urgency of care needed) and whether the kinds of services provided meet the need of the user.17,18  In the health care system, patient satisfaction has emerged as an important component that determines consumer choice of a product or service.19 Determining the factors responsible for rural patient’s choice of health care providing facility cannot be measured without considering several factors broadly grouped into Health System Related Factors and Individual-Related Factors

1.2 STATEMENT OF PROBLEM
Health care utilisation is the use of health care services by people. Utilization of healthcare services is an important determinant of health and has particular relevance as a public health and development issue in low income countries20. There are so many factors that have been identified by researchers for poor utilization of modern health facilities. The choice of health facilities for healthcare by an individual is largely determined by his/her taste, satisfaction with service and the perceived quality of care provided.21 The under-utilisation of the health services in public sector has been almost a universal phenomenon in developing countries. 22 While public primary health care (PHC) centers are relatively uniformly distributed throughout local government areas (LGAs) in Nigeria, the rural people tend to underuse the basic health services. For example, while less than half of PHC facilities in Nigeria provide antenatal care (ANC), a reproductive health resource inventory carried out by FMOH and WHO found that almost 60% of PHC offering  ANC and delivery services had no midwives and another 17% had neither midwives nor senior community extension workers.23 This has rendered them underutilized sometimes making the tertiary facilities overburdened .24
There seem to be higher use of private health facilities. This could be attributed mostly to issues of easy access, shorter waiting time, longer or flexible opening hours, better availability of staff and drugs, better attitude and more confidentiality in socially stigmatized diseases. 20The utilization of private hospital was affected by the household size, the distance of available hospital from home and the total cost of seeking health service .25 However, in private hospitals, the quality of services, the responsiveness and discipline of the provider has been questionable26,27,28,29

1.3 JUSTIFICATION OF STUDY
In Nigeria, health care system comprises both public and private health facilities.15 For one to be able to maintain a healthy state, the choice of health care services and predictors of the choice are important. The health and health-related problems of rural people include poverty, high endemic diseases prevalence, low level of available healthcare facilities/infrastructures in the rural areas to mention a few30,31. These affect their health seeking behaviour, in this case health facility utilization compared with those individuals in the urban setting. An assessment of these problems and needs is important to assure the utilization of public health facilities for health care services by rural people. The behaviour of the patient which is made evident by their choice of health care provider may also give an insight into how these health facilities can improve on their service delivery, improve client satisfaction and by extension ensure a healthier population.19 Other reasons for research of this type includes support for consumer choice, enabling accountability, and quality promotion on the part of health providers.....

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