Perception And Utilization Of Public Health Services In Southeast Nigeria: Implication For Health Care In Communities With Different Degrees Of Urbanization

Child and maternal deaths have experienced a significant reduction, reflecting progress towards the health-linked Millennium Development Goals (MDG) globally [1]. Between 1990 and 2013, global under-five mortality declined from 12.7 million to 6.3 million and maternal mortality ratio dropped from 380 to 210 per 100,000 live births [2]. However, the proportion of child and maternal deaths recorded in sub-Saharan Africa increased [3]. In Nigeria, for instance, maternal mortality ratio increased from 545 to 575 deaths per 100,000 live births between 2008 and 2013 [4, 5], reflecting a worsening situation [4, 6]. Interventions have been designed to reduce maternal mortality and achieve the MDG target of 250 or less deaths per 100,000 live births in Nigeria. Maternal and child health continue to worsen, despite the government’s partnership with the private sector to promote improved access to quality maternal health services [6].

The current realities indicate that the huge global and national investments aimed at effective health care delivery have not yielded the desired results because of poor utilization and ultimately low access. According to Frost and Reich [7], availability of interventions and services does not translate automatically to access. Access implies effective and appropriate utilization of the interventions and services by the intended clientele. Poor access to health facilities and services was identified as a factor militating against efforts to address major health problems in Africa [8].

Gaps have also been revealed between need and actual access to some critical health services [4]. Sixty-one percent of mothers in Nigeria received antenatal care from a skilled provider. Of this proportion, only 51 % made at least four antenatal care visits during pregnancy. This gives a 49 % point drop in utilization between the first and fourth usage. In terms of child health, only 19 % of the children (aged 12–23 months at survey time) received all the basic vaccinations as shown in the vaccination cards. The third of diphtheria, pertussis and tetanus (DPT3) vaccine, used as proxy for vaccine utilization, recorded only 22.2 % use, whereas DPT1 was 26.7 %.

Perception has come up a prominent determinant of the utilization of health services. According to Roberts et al. [9], “…utilization is only partially a reflection of effective availability, as patients may choose not to use services, even if they are available”. The decision to use available health services depends on people’s perception of the services and affordability. People’s perceptions and judgment are often conditioned by assessing factors their traditions and culture consider important such as courtesy, responsiveness, attentiveness, and perceived competence of the health staff [10]. Perceptions are determined by the people’s level of satisfaction with the health service, as well as their assessment of the attitude of health workers, which often determines whether they would return in future. To achieve universal health for the people, it is imperative that all stakeholders understand the people’s perception of health service, to ensure successful interventions. This is critical to developing appropriate promotional messages and campaigns, aimed at creating demand for particular health interventions [11].

Social-psychologists argue that perception, in the context of health, is structured on the basis of variables like ‘risk perception’ (the degree to which one feels susceptible to certain health risk), ‘self-efficacy’ (confidence in one’s ability to take the necessary action) and ‘action-outcome expectancies’ (ones belief that the proposed action is contributory to the expected outcome) [12–18]. Others stressed that these variables tend to produce motivation to adhere to healthier behaviours (precautionary motivation) that may lead to an intention to carry out these behaviours [19, 20]. It has also been argued that health care utilization is a function of both need-related factors as well as supply-induced and thus strongly dependent on the structures of the health care system [21]. Anderson’s behavioural model captures these different domains aptly in its multilevel model that incorporates both individual predisposing factors and contextual or health provider determinants of health service use otherwise called enabling and need factors [22]. However, data on perceptions of health interventions and services have generally been collected quantitatively with comparatively low reliance on qualitative methods of inquiry [23–30]. This study adopted the mixed-method approach, in assessing the perceptions of people in Southeast Nigeria and how it influences their utilization of public health facilities and services (that is primary health care).

Keywords: Perception, utilization, health services, Nigeria