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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