Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 1 ORIGINAL RESEARCH Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria David Ayobami Adewole1, Temitope Ilori2 1Department of Health Policy and Management, College of Medicine, University of Ibadan, Nigeria; 2Family Medicine Unit, Department of Community Medicine, College of Medicine, Univer- sity of Ibadan, Nigeria; Corresponding author: David Ayobami Adewole; Address: Department of Health Policy and Management, College of Medicine, University of Ibadan, Nigeria; Telephone: +234 8034052838; Email: ayodadewole@yahoo.com mailto:ayodadewole@yahoo.com Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 2 Abstract Aims: Factors that influence the personal choice of a health care facility among health care consumers vary. Currently, what influences the choice of health facilities among enrollees under the National Health Insurance Scheme (NHIS) is not known. This study aimed to as- sess what influences the choice of facilities in the NHIS of Nigeria. Methods: This was a descriptive cross-sectional study conducted among enrollees in selected NHIS facilities in the 11 Local Government Areas (LGAs) of Ibadan, Nigeria. A total of 432 enrollees were selected and were interviewed. A WHO-USAID semi-structured interviewer- administered questionnaire was used to obtain relevant data. Data collection was between Oc- tober and December 2019. Data were analyzed using STATA version 12.0 (α =0.05). Results: At unadjusted OR, older respondents (OR 3.24, CI = 2.52-4.18, p = <0.0001), and those who had attained the tertiary level of education (OR 3.30, CI 2.57-4.23, p <0.0001) were more likely to make a personal choice of health care facilities. A similar pattern was ob- served among respondents who were in the high socioeconomic group (OR 4.10, CI 3.01- 5.59, p = <0.0001). However, at Adjusted OR, only high socio-economic status was a predic- tor of personal choice of health care facility (OR 1.92, CI 1.21-3.05, p = 0.005). Conclusion: This study is suggestive that a need for and the ability to afford the cost of care influence the choice of health facilities. Policies that promote health literacy in the general populace will enhance the capability of individuals to make a personal choice of health facili- ties. Stakeholders should prioritize this for policy. Recommended citation: David A. Adewole, Temitope Ilori. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria Keywords: choice, National Health Insurance Scheme, personal, health facility, enrolees Acknowledgments: The authors wish to acknowledge study participants for permission to interview them in the course of the data collection of this study. Authors' contributions: David Adewole conceived and designed the study. Temitope Ilori did data collection and analysis. Both authors contributed equally to the manuscript write-up. The two authors also read through the manuscript draft the second time and agreed to the final manuscript. Conflict of interests: None declared. Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 3 Introduction While some studies suggest that patients ac- tively choose healthcare facilities evi- denced by a significant level of health liter- acy (1), a substantial proportion of patients do not consider the choice to be very im- portant (2). Many factors have been as- cribed to influence the choice of healthcare facilities. Reliance on physician advice/re- ferrals, advice of friends and relatives, and patronizing the nearest health care facilities are some of the means of choosing health care facilities. Socio-demographic factors such as age, sex, educational status and so- cioeconomic status, cost of care, the sever- ity of illness, existence of multiple morbid- ities/comorbidity, and past experiences with a facility all influence choice in differ- ent ways. Cost of care and the ability to pay to play a role in the active choice of facili- ties (3). However, for those who are on a health care plan, the cost of care may not necessarily be an incentive in the choice of a preferred health care facility as health in- surance organizations partly determine the facilities that are available to patients (4). The National Health Insurance Scheme (NHIS) of Nigeria is a social health insur- ance program established in the year 2005. Currently, the total population coverage is 4 million lives, of which the formal sector constitutes 64% compared with the infor- mal sector. Major stakeholders in the scheme are the NHIS (government) offi- cials, which provide policy guidelines, the Health Maintenance Organizations (HMOs) who are the insurers, and health care providers. By the Act that established the scheme, enrolment in the scheme is vol- untary. A principal enrollee is entitled to register a spouse and four children below the age of eighteen years under the scheme. The principal enrollee chooses a health care facility to receive care (5). Presently, it’s not clear what factors influence the choice of health care facilities among enrollees in the scheme. The present study aimed to de- termine this. Findings would be useful to understand better the level of health literacy of enrollees under the scheme. This will provide an avenue to addressing any exist- ing deficiency in the process of choice of facilities. This could serve as a guide in similar schemes and settings. Methods Study design and area: This is a descriptive cross-sectional study. It was conducted in the 11 Local Govern- ment Areas (LGAs) of Ibadan, Nigeria. The 11 LGAs were made up of 5 urban and 6 semi-urban areas. The semi-urban LGAs formed an outer ring of the inner 5 LGAs (6). The estimated population of the 11 LGAs was about 3 million based on the pro- jection using the figure from the 2006 Ni- geria population census as the base year (7). There were several health care facilities at the primary, secondary, and tertiary care levels in the study area. Sample size estimation In this study, factors that influence the choice of health care facilities are the main outcome variable. Satisfaction with ser- vices is known to influence the choice of fa- cilities, the proportion of the enrollees who were satisfied with the choice of a facility in a previous study in Nigeria was 40.7% (8). Using the Leslie-Kish formula, (9) cal- culated minimum sample size was 420. Sampling strategy: A list of all health care facilities within the study area (11 LGAs); primary, secondary, and tertiary care level facilities was ob- tained from the Oyo State Ministry of Health. Next, a list of all NHIS accredited facilities within the study area was obtained from the NHIS Office in Ibadan. For the choice of enrolees, eleven (11) NHIS ac- credited health facilities, one (1) facility in Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 4 each of the 11 LGAs were selected by sim- ple random sampling. The selected facili- ties were visited and the number of enrol- lees in each of these facilities was verified. Proportional allocation of the estimated sample size (420) was done based on the number of enrollees across the selected NHIS accredited facilities. Profile of selected facilities There are three levels of care in the health system of Nigeria. These are the primary, secondary, and tertiary levels. The primary is the first level of care and entry point of individuals to the health system. The sec- ondary serves as the referral centre for the primary, while the tertiary is the referral centre for the secondary level. The second- ary provides general medical and laboratory services, as well as specialized health ser- vices, such as surgery, pediatrics, obstet- rics, and gynecology to patients referred from the primary health care level, and this is generally uniform. Ownership of these facilities cuts across the private and the public (government). Ownership in the pri- vate sector is either private profit-based or non-for-profit faith-based organizations (10). In the NHIS arrangement, the primary level of care is not engaged to provide ser- vices. There is only one (1) tertiary level fa- cility within the study area. Only the sec- ondary and the tertiary levels do. In this study, only the secondary level of care fa- cilities was selected. Due to the small num- ber (only one [1] in the study area) com- pared to NHIS accredited secondary health care facilities, and also because of better in- frastructural facilities and human resources availability compared to secondary health care facilities, the only available tertiary health care facility in the study area was not selected. All faith-based health care facili- ties in the study area (three – 3) were how- ever purposefully selected into the study, while others (non-faith-based private) were selected using stratified systematic sam- pling to allow for a representation method of sampling. Participants’ selection A list of NHIS enrolees waiting to receive care in the outpatient unit of a selected health facility was obtained from the medi- cal records department of the facility. Eligi- ble individuals were the principal enrolees or spouses (excluding dependents under the age of 18 years) and had enrolled in the fa- cility for at least one year before the com- mencement of the study. This was to in- crease the possibility that study participants had an appreciable level of interaction with the health system under the scheme that will enable appropriate responses from them (8). Among this population, enrollees who began using the selected facilities before the commencement of the health insurance scheme, as well as enrollees who were health care workers in these facilities were excluded from the study. A sampling frame was generated, a sampling interval was de- termined, and systematic random sampling was used to select eligible participants. Sys- tematic sampling was chosen because it eliminates the phenomenon of clustered se- lection and a low probability of data con- tamination. The disadvantage of using a systematic sampling technique is noted and is considered a study limitation. The hospi- tal card numbers of the enrollees who were interviewed were documented and kept safe. Data collection Selected enrolees (n = 420) in the selected NHIS accredited health facilities were in- terviewed with the aid of an adapted WHO- USAID Demographic and Health Survey semi-structured interviewer-administered questionnaire (United States Agency for In- ternational Development. The Demo- graphic and Health Surveys). Enrolees who had earlier been interviewed during the study but came back to the clinic for care Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 5 were deliberately identified and excluded. This was done so as not to interview such individuals a second time, and it was car- ried out by cross-checking the hospital number of the prospective interviewee (en- rolee) in the list of hospital numbers that were earlier documented for safekeeping. This exercise was repeated daily until the allocated number of enrollees in each of the facilities was interviewed. Quantitative data analysis Choice of health care facilities was catego- rized into personal and choice-based on ad- vice. While personal choice is the one made by the individual enrolee, a choice based on advice was the one made with the assistance of other individuals and entities such as friends and colleagues, referral physicians, family members, and insurers. Quantitative data were analyzed using STATA. A Chi- square test was used to determine the asso- ciation between socio-demographic charac- teristics and the choice of health care facil- ity. Following this, statistically significant variables (α = 5%) were entered into multi- ple logistic regression models to determine the strength of association between the de- pendent and independent variables (predic- tors). Results The data as shown in Table 1 depicts that more than three-quarters, 331(76.6%) of the respondents were at least 35 years of age. About three-fifths, 263 (60.9%) of the re- spondents were females, while 344 (79.6%) had tertiary level of education, 319 (73.8%) were civil servants. Those who were in the high socio-economic status were more, 255(59.0%) compared to those who were in the low group. About one-third of 134 (31.0%) claimed to have multiple morbidi- ties, and 219 (67.4%) sought information about the quality of service in the facility before enrolment. Almost three-quarters, 320 (74.1%) of the study participants claimed to have personally chosen health care facilities where current care is received under the scheme. The total number of re- spondents eventually interviewed was 432 (2.8% above the minimum estimated sam- ple size). Table 1: Sociodemographic characteristics of respondents Socio-demographic characteristics Frequency N = 432 Percent Age Group < 35 years 101 23.4 35 and above 331 76.6 Sex Male 169 39.1 Female 263 60.9 Marital Status Married 415 96.1 Others 17 3.9 Level of Education Less than Tertiary 88 20.4 Tertiary 344 79.6 Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 6 Table 2 below shows the distribution of respondents by socio-de- mographic characteristics and by sector. The majority, 319 (73.8%) were civil serv- ants. Overall, on the choice of health care facilities, the proportion of those who made a personal choice of facilities among civil servants compared with those who were from the pri- vate sector was much higher. However, this was not statistically significant: χ2 = 0.06, p = 0.94. However, choice of facilities was sig- nificant across age groups, χ2 28.33, p <0.001, level of education χ2 10.6, p = 0.001, and status of co-morbidities χ2 12.2 p <0.001. Table 2: Distribution of respondents by socio-demographic characteristics and by place of work Socio-demographic characteristics Public n(%) Private n(%) χ2 (P-value) Age Group 28.33(<0.001) < 35 years 54 (53.5) 47(46.5) 35 and above 265(80.1) 66(19.9) Sex 2.1 (0.11) Male 132(78.1) 37(21.9) Female 187(71.1) 76(28.9) Marital Status Married 305(73.5) 110(26.5) Others 14(82.4) 3(17.6) Level of Education 10.6 (0.001) Less than Tertiary 53(60.2) 35(39.8) Tertiary 266(77.3) 78(22.7) Socio-economic Status 0.13(0.71) Low 129(72.9) 48(27.1) Occupation Civil Servant 319 73.8 Private 113 26.2 Socio-economic Status Low 177 41.0 High 255 59.0 Presence of multiple morbidities Absent 298 69.0 Present 134 31.0 Prior information about quality of care in facility Yes 291 67.4 No 141 32.6 Method of choice of facility Personal Choice 320 74.1 Choice based on Advice 112 25.9 Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 7 High 190(74.5) 65(25.5) Presence of multiple morbidities 12.2 (<0.001) Absent 235(78.9) 63(21.1) Present 84(62.7) 50(37.3) Prior information about quality of care in facility 0.01(0.98) Yes 215(73.9) 76(26.1) No 104(73.8) 37(26.2) Method of choice of facility 0.06 (0.94) Personal Choice 236(73.8) 84(26.2) Choice based on Advice 83(74.1) 29(25.9) Table 3 below shows the pattern of choice of health care facilities among NHIS enrol- lees. Generally, respondents claimed the health care facilities where they enrolled for care under the scheme were chosen by per- sonal choice. However, older respondents, married individuals, and those who attained a tertiary level of education were signifi- cantly more likely to do so than their re- spective counterparts ( 2  4.11, p = 0.043; 2  6.73, p = 0.01; 2  6.27, p = 0.012) re- spectively. Also, choice of health care fa- cilities was statistically significant among respondents who were in high socioeco- nomic status compared with those who were in the low group, ( 2  12.94, p = <0.00001) and as well among those who had multiple morbidities compared with those who were otherwise ( 2  4.30, p = 0.038). Table 3: Percentage distribution of the enrolees according to choice of health care facili- ties by socio-demographic characteristics Personal Choice Choice based on ad- vice Total 2  P-value Socio-demographic characteristics Age group 4.11** 0.043 < 35 years 67(66.34) 34(33.66) 101 35 and above 253(76.44) 78(23.56) 331 Sex 0.034 0.855 Male 126(74.56) 43(25.44) 169 Female 194(73.76) 69(26.24) 263 Marital Status 6.73*** 0.01 Married 312(75.18) 103(24.82) 415 Others 8(47.06) 9(52.94) 17 Level of Education 6.27** 0.012 Less than Tertiary 56(63.64) 32(36.36) 88 Tertiary 264(76.74) 80(23.26) 344 Occupation 0.0055 0.941 Civil Servant 236(73.98) 83(26.02) 319 Private 84(74.34) 29(25.66) 113 Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 8 At Adjusted OR, while the presence of mul- tiple morbidities was weakly significantly associated with a personal choice of health care facility (OR 1.63, CI 0.97-2.74, p = 0.063, being in the high socio-economic class was highly significantly associated with a personal choice of health care facility (OR 1.92, CI 1.21-3.05, p = 0.005). Table 4 (below). Table 4: Logistics regression model of predictors of personal choice of facilities among respondents Socio-economic Status 12.94*** <0.00001 Low 115(64.97) 62(35.03) 177 High 205(80.39) 50(19.61) 255 Multiple Morbidities Absent 212(71.14) 86(28.86) 298 4.30** 0.038 Present 108(80.6) 26(19.4) 134 Information on quality 0.69 0.405 Yes 212(72.85) 79(27.15) 291 No 108(76.60) 33(23.40) 141 Closer facility 2.01 0.157 Yes 115(78.23) 32(21.77) 147 No 205(71.93) 80(28.07) 285 Socio-demographic characteristics Unadjusted OR Adjusted OR OR 95% C.I p-value OR 95% C.I p-value Age group < 35 years (ref.) 35 and above 3.24*** 2.52-4.18 <0.0001 1.56 0.89-2.73 0.123 Sex Male 2.93*** 2.07-4.14 <0.0001 0.88 0.56-1.40 0.601 Female (ref.) Marital status Married 3.03*** 2.42-3.78 <0.0001 0.86 0.42-1.79 0.691 Others (ref.) Level of education Less than Tertiary (ref.) Tertiary 3.30*** 2.57-4.23 <0.0001 1.47 0.88-2.48 0.145 Occupation Civil Servant (ref.) Private 2.90*** 1.90-4.42 <0.0001 1.08 0.63-1.84 0.781 Socio-economic status Low (ref.) High 4.10*** 3.01-5.59 <0.0001 1.92*** 1.21-3.05 0.005 Multiple morbidities Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 9 Dis- cus- sion The older age group respondents were more than double the younger ones. This is at var- iance with the 2013 NDHS and other re- ports that the age distribution of Nigeria population and similar other countries in the sub-Saharan African Countries (SSA) characteristically have (5, 11, 12). The ob- servation in this study may be partly due to a long embargo on employment in the for- mal sector that has resulted in the popula- tion of the current formal sector employees, the majority of whom constituted the study respondents, has grown to older age without a concomitant younger population for a gradual replacement. Another factor could be that the study population (NHIS enrol- ees) was restricted to a select privileged few unlike if the selection were to be from a more representative general population. However, the population distribution of re- spondents by sex and by enrolment under the NHIS, and by marital status reflects the latest NDHS Reports (11, 13). The higher proportion of female respondents may be a reflection of the known better health-seek- ing behaviour among women compared to that of men (14). It is an expected observa- tion that the majority of the respondents’ at- tained tertiary level education as enrollees under the NHIS are mainly individuals in the formal sector employment of the Fed- eral Government of Nigeria (5). In this study, respondents who were civil servants were almost three times those who were from the private sector. This is in order with credible sources that only a handful of the present enrollees under the NHIS were vol- untary/private contributors (5, 15). This is also similar to the general pattern observed in some other countries, such as in Ghana (16) and Kenya, in these countries as it is common in other poor developing SSA countries, the design of social health insur- ance schemes tends to be unfavourable for the informal sector population who, com- pared with those in the formal sector, are usually burdened with low and inconsistent income (4). As a result, the majority of the people in this category are compelled to pay health care costs through of pocket method which is associated with the inequity of ac- cess to health care and poor health out- comes (17). Contextually designed strate- gies to addressing these challenges will as- sist in turning around the picture and mini- mize the likely inequity of access among the informal sector population. Several factors interplay differently in dif- ferent health situations in the same individ- ual to influence the choice of health care fa- cilities. These factors cut across both the consumer and facility sides of the health care market. Literature on the choice of health care facilities generally agrees that health care consumers hardly make an ac- tive choice of facilities/facilities (2), and, that they more often than do not consider the choice of health facilities to be im- portant. As a result, consumers mostly rely Absent (ref.) Present 4.30*** 2.71-6.37 <0.0001 1.63* 0.97-2.74 0.063 Prior information about quality of care in facility Yes (ref.) No 3.27*** 2.22-4.83 <0.0001 1.12 0.69-1.82 0.642 Knowledge of NHIS fa- cility closer to residence Yes 3.59*** 2.43-5.32 <0.0001 1.21 0.75-1.98 0.432 No (ref.) Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 10 on the assistance of others for the choice of health facilities (2, 18). For that purpose, friends, family members, and general prac- titioners are the usual sources of influence (18, 19). In addition to these, the presence or absence of a health insurance policy also influences the choice of facilities since in most cases, insurers determine the specific facilities that are available to health care consumers (2, 20). In addition, a knowledge of the quality of the care, (21) and the di- mensions of care, functional and technical (22) available in health care facilities play a role in the choice of health facilities espe- cially when individuals are well informed about such (1). Health care consumers’ at- tributes such as age, sex, marital status, level of education, and type of occupation are also some of the factors that influence the choice of facilities (2, 20). Others are the socio-economic status as well as the presence or absence of comorbidities and perceived severity of illness in individuals (23, 24). There are contrary opinions about the younger age group, while some claimed that this group of people make an active choice of facilities, (2), some are of the con- trary view, and that passive choice is more common among them (20, 25). Female sex was reported to be associated with passive choice in a previous study in Nigeria (26). Highly educated individuals and those in the high socioeconomic group have been reported to be more likely to actively choose health care facilities (24, 27). In this study, the personal choice of health care fa- cilities was more likely with more vulnera- ble individuals such as being married, older individuals, and the presence of multiple morbidities. Findings from previous studies corroborate these findings that this category of people is less likely to tolerate the risk of uncertainties and thus, are less favourably disposed to accepting the choice of health care facilities through a third party (2, 20, 23, 28). Also, the acquisition of tertiary ed- ucation and being in the high socio-eco- nomic class was associated with the active choice of health care facilities. In this envi- ronment, the tertiary level of education is a factor of employment in the formal sector (civil service), who characteristically enjoy a consistent and higher level of income compared with those in the informal sector (4). The synergy of higher income and ed- ucation could be a strong factor in exposure to better access to beneficial health-related information. This inadvertently enhances the health literacy of such individuals and the tendencies to obtain, process, and com- pare different health care facilities and ser- vices while making a choice (1). It is note- worthy that, when health care consumers have the privilege to choose health care fa- cilities and insurers, it encourages healthy competition, which in turn enhances effi- cient delivery of quality health services (2, 18, 29, 30). However, of all the factors as- sociated with a personal choice of health fa- cility, high socio-economic status and the presence of multiple morbidities had more influence in the choice of health facilities. It should be noted that the number of those who claimed personal choice of a health fa- cility was almost three times the number of those who claimed a choice based on ad- vice. This finding was in disagreement with the generally held pattern of passive selec- tion of health care facilities by the majority of consumers compared to a few who do ac- tive selection (2, 18, 19). Again, high socio- economic class and level of education among the respondents in this study could be contributory factors. In conclusion, this study shows that various socio-demo- graphic factors influence the choice of health facilities among individuals. How- ever, a need for and the ability to afford the cost of care influences the choice of health facilities the most, as demonstrated by the presence of multiple morbidities and a high socio-economic class. It should also note- worthy that the majority made a personal choice of health facilities. This may not be unconnected with a high level of general lit- eracy which may have had a direct impact Adewole DA, Ilori T. Factors influencing the choice of facilities among enrolees of a prepayment scheme in Ibadan, Southwest Nigeria (Original research). SEEJPH 2021, posted: 12 May 2021. DOI: 10.11576/seejph-4430 11 on health literacy. Stakeholders should note this for policy purposes. As an empha- sis on the benefits of personal choice of health facility, it is recommended that health literacy is promoted in the general populace. This will promote healthy com- petition among health care facilities and providers and enhance the efficient delivery of quality health care. 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