ABSTRACT

The utilization of public healthcare services among adolescents in Nigeria remains critically low despite the availability of such services in many localities. This study investigated the socioeconomic determinants of low utilization of public healthcare services among adolescents in Aba South Local Government Area (LGA) of Abia State, Nigeria. The study adopted a descriptive cross-sectional research design and collected primary data from 384 respondents selected through a multi-stage sampling technique. A structured questionnaire was used as the primary instrument of data collection, and data were analysed using descriptive statistics and the chi-square test of hypothesis.

Findings revealed that household income level, parental educational attainment, health insurance coverage, proximity to health facilities, cost of healthcare services, and awareness of available services were major socioeconomic factors significantly influencing healthcare utilization among adolescents in the study area. Adolescents from low-income households, whose parents had little or no formal education, and who lived more than five kilometres from public health facilities, were significantly less likely to utilize public healthcare services. Out-of-pocket payment requirements, long waiting times, perceived poor quality of care, and stigma were also identified as key barriers.

The study concluded that socioeconomic inequalities constitute major barriers to adolescent healthcare utilization in Aba South LGA and recommended that government should strengthen health insurance schemes targeting low-income adolescents, improve the distribution and quality of public health facilities, and intensify health literacy campaigns in schools and communities.

Keywords: Socioeconomic determinants, healthcare utilization, adolescents, public health services, Aba South, Abia State, Nigeria.

Here is your clean Table of Contents without dotted leaders:

TABLE OF CONTENTS

Declaration ii
Certification iii
Dedication iv
Acknowledgements v
Abstract vi
Table of Contents vii
List of Abbreviations ix

CHAPTER ONE: INTRODUCTION

1.1 Background to the Study 1
1.2 Statement of the Problem 5
1.3 Objectives of the Study 7
1.4 Research Questions 8
1.5 Research Hypotheses 8
1.6 Significance of the Study 9
1.7 Scope of the Study 10
1.8 Limitations of the Study 11
1.9 Definition of Key Terms 12

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction 14
2.2 Conceptual Framework 14
2.3 Conceptual Literature 18
2.4 Theoretical Literature 26
2.5 Empirical Literature 33
2.6 Literature Gap 42

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Introduction 44
3.2 Research Design 44
3.3 Population for the Study 45
3.4 Sample Size and Sampling Techniques 46
3.5 Method of Data Collection 48
3.6 Sources of Data 49
3.7 Instrument of the Study 49
3.8 Method of Data Analysis 51
3.9 Validity and Reliability of the Data 52

CHAPTER FOUR: DATA PRESENTATION AND ANALYSIS

4.1 Presentation and Analysis of Data 54
4.2 Test of Hypothesis 72

CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Summary 78
5.2 Conclusion 80
5.3 Recommendations 81

References 84
Appendix 91

If you want, I can also format it into a perfect MS Word project template (with automatic TOC, headings, and page numbering).

LIST OF ABBREVIATIONS

AFHS Adolescent-Friendly Health Services

BHCPF Basic Health Care Provision Fund

CSDH Commission on Social Determinants of Health

HBM Health Belief Model

HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

HMIS Health Management Information System

LGA Local Government Area

LMIC Low- and Middle-Income Country

NBS National Bureau of Statistics

NDHS Nigeria Demographic and Health Survey

NHIA National Health Insurance Authority

NHIS National Health Insurance Scheme

NPC National Population Commission

NPHCDA National Primary Health Care Development Agency

OOP Out-of-Pocket

PHC Primary Health Care

SDH Social Determinants of Health

SES Socioeconomic Status

SRH Sexual and Reproductive Health

STIs Sexually Transmitted Infections

TPB Theory of Planned Behaviour

UHC Universal Health Coverage

UNICEF United Nations International Children's Emergency Fund

WHO World Health Organization

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The health of adolescents constitutes a cornerstone of national development, as this population group represents both the present and future workforce of any nation. Adolescents, broadly defined by the World Health Organization (WHO) as individuals between the ages of 10 and 19 years, account for approximately 18% of the global population and about 23% of Nigeria's population (WHO, 2021; NPC, 2020). Despite their numerical significance and the critical nature of adolescence as a transitional stage of life, this population group remains one of the most underserved in terms of healthcare access and utilisation, particularly in developing countries like Nigeria.

Public healthcare services are government-provided or government-subsidised health services designed to be accessible and affordable to all citizens. In Nigeria, public healthcare delivery is structured at three levels: primary, secondary, and tertiary care. The Primary Health Care (PHC) system, established following the Alma Ata Declaration of 1978 and localised through the National Primary Health Care Development Agency (NPHCDA), is designed to serve as the first point of contact between individuals and the health system. Despite decades of investment and policy reforms, utilisation of public healthcare services especially at the primary level remains abysmally low among adolescents in many parts of the country.

Abia State, located in South-Eastern Nigeria, is characterised by a mix of urban and peri-urban communities. Aba South Local Government Area, one of the seventeen LGAs in the state, is a densely populated commercial hub with a large adolescent population. The area is served by several government health facilities including general hospitals, PHC centres, and community health posts. However, anecdotal evidence and preliminary observations suggest that adolescents in Aba South rarely visit these public facilities for health services, preferring instead to seek care from private clinics, patent medicine stores, or resorting to self-medication (Abia State Ministry of Health, 2022).

Globally, the determinants of healthcare utilisation are multifaceted and encompass biological, psychological, social, cultural, economic, and structural factors. Among these, socioeconomic determinants have been consistently identified as the most powerful predictors of healthcare access and utilisation, particularly in low- and middle-income countries (LMICs). Socioeconomic factors such as household income, parental education, employment status, health insurance coverage, cost of services, and proximity to health facilities significantly shape whether individuals especially adolescents seek and receive healthcare (Andersen, 2008; Victora et al., 2018).

In Nigeria, economic hardship facing a large proportion of the population translates into limited capacity to pay for healthcare, even at ostensibly subsidised public facilities. Out-of-pocket (OOP) expenditure remains the predominant mode of healthcare financing, accounting for over 70% of total health expenditure in Nigeria (World Bank, 2023). For adolescents from low-income households, the financial burden associated with accessing public health services including transport costs, consultation fees, and medication costs constitutes a formidable barrier.

Parental education also plays a critical role, as educated parents are more likely to recognise health needs, understand health information, and facilitate healthcare-seeking behaviour in their adolescent children (Onyeneho et al., 2019). Furthermore, structural factors including the geographic distribution of health facilities, quality of infrastructure, availability of essential medicines, and the attitude of healthcare workers are known to influence utilisation patterns. In many communities within Aba South, public health facilities are characterised by inadequate staffing, poor infrastructure, limited availability of medicines, and unfriendly provider attitudes factors that discourage adolescents from utilising these services (Nwachukwu et al., 2020).

The consequences of low healthcare utilisation among adolescents are grave. Unmet healthcare needs during adolescence can lead to preventable morbidity and mortality, poor reproductive health outcomes, increased vulnerability to infectious diseases including HIV/AIDS, and impaired physical and mental development (UNICEF, 2021). While existing studies have examined healthcare utilisation in Nigeria, most have focused on maternal and child health or adult populations, and none to the knowledge of this researcher has focused specifically on Aba South LGA of Abia State. This study therefore fills an important gap by examining the socioeconomic factors that determine low utilisation of public healthcare services among adolescents in Aba South, with the aim of generating evidence-based recommendations for policy and practice.

1.2 Statement of the Problem

Public healthcare services in Nigeria are theoretically designed to be accessible and affordable for all citizens, including adolescents. The government, through the NPHCDA and the Abia State Ministry of Health, has established a network of public health facilities in Aba South LGA to cater to the healthcare needs of the population. However, despite the existence of these facilities, utilisation rates among adolescents remain persistently low. Preliminary observations and health facility records indicate that adolescents constitute a disproportionately small share of patients attending public health facilities in the LGA, relative to their population size (Abia SMOH, 2022).

This low utilisation is not merely a statistical anomaly; it has real consequences for the health and wellbeing of adolescents. Unmet healthcare needs expose adolescents to preventable illnesses, reproductive health complications, mental health challenges, and nutritional deficiencies. The burden of these unmet needs ultimately falls on individuals, families, communities, and the healthcare system as a whole.

The problem is particularly concerning given the socioeconomic context of Aba South LGA. A significant proportion of households in the area live below the poverty line, with many engaged in low-income informal commercial activities. Parental educational attainment is variable, with a notable proportion of households characterised by low literacy levels. These socioeconomic realities are expected to intersect with structural health system factors to create multiple barriers to adolescent healthcare utilisation.

Despite growing recognition of this problem, there is a dearth of empirical evidence specifically examining the socioeconomic determinants of low healthcare utilisation among adolescents in Aba South LGA. Without such evidence, it is difficult for policymakers and health planners to design targeted interventions. This study is therefore motivated by the urgent need to generate locally relevant evidence on the socioeconomic determinants of low utilisation of public healthcare services among adolescents in Aba South LGA of Abia State.

1.3 Objectives of the Study

The broad objective of this study is to examine the socioeconomic determinants of low utilisation of public healthcare services among adolescents in Aba South LGA of Abia State. The specific objectives are to:

i. Identify the socioeconomic characteristics of adolescents and their households in Aba South LGA;

ii. Assess the level of utilisation of public healthcare services among adolescents in Aba South LGA;

iii. Examine the influence of household income on the utilisation of public healthcare services among adolescents in the study area;

iv. Determine the relationship between parental educational attainment and adolescent healthcare utilisation in Aba South LGA;

v. Assess the effect of proximity to health facilities on adolescent healthcare utilisation in the study area;

vi. Identify other non-economic barriers that contribute to low healthcare utilisation among adolescents; and

vii. Recommend evidence-based strategies for improving adolescent healthcare utilisation in Aba South LGA.

1.4 Research Questions

This study was guided by the following research questions:

i. What are the socioeconomic characteristics of adolescents and their households in Aba South LGA?

ii. What is the level of utilisation of public healthcare services among adolescents in Aba South LGA?

iii. To what extent does household income influence the utilisation of public healthcare services among adolescents in the study area?

iv. What is the relationship between parental educational attainment and adolescent healthcare utilisation in Aba South LGA?

v. How does proximity to health facilities affect adolescent healthcare utilisation?

vi. What other non-economic barriers contribute to low healthcare utilisation among adolescents in Aba South LGA?

1.5 Research Hypotheses

The following null hypotheses were formulated and tested in this study:

Ho1: There is no significant relationship between household income level and the utilisation of public healthcare services among adolescents in Aba South LGA.

Ho2: There is no significant relationship between parental educational attainment and the utilisation of public healthcare services among adolescents in Aba South LGA.

Ho3: There is no significant relationship between proximity to public health facilities and the utilisation of public healthcare services among adolescents in Aba South LGA.

1.6 Significance of the Study

This study holds considerable significance at multiple levels. Theoretically, it contributes to knowledge on adolescent health-seeking behaviour by applying and extending key theoretical frameworks including the Andersen Behavioural Model of Health Services Utilization and the Health Belief Model to the Nigerian context. Empirically, the study generates original, locally relevant data on the socioeconomic determinants of adolescent healthcare utilisation in Aba South LGA, filling an important gap in the literature on adolescent health in South-Eastern Nigeria.

From a policy perspective, the findings are expected to be of direct relevance to health policymakers at the federal, state, and local government levels. The study's recommendations provide actionable guidance for designing interventions to improve adolescent healthcare utilisation, including reform of health financing mechanisms, expansion of health insurance coverage, and improvement of healthcare infrastructure. Health planners in the Abia State Ministry of Health and NGOs working on adolescent health will similarly benefit from this study's evidence in identifying priority areas for intervention.

1.7 Scope of the Study

This study focuses on the socioeconomic determinants of low utilisation of public healthcare services among adolescents in Aba South Local Government Area of Abia State, Nigeria. The study is geographically delimited to Aba South LGA. The population of study consists of adolescents aged 10 to 19 years residing in selected communities within the LGA. The study examines socioeconomic variables including household income, parental education, employment status, health insurance coverage, and cost of healthcare services, as well as structural variables such as proximity to health facilities and quality of care. The study focuses specifically on public healthcare facilities and was conducted between [month] and [month] of [year].

1.8 Limitations of the Study

This study encountered several limitations. First, the study relied primarily on self-reported data from adolescent respondents, which is susceptible to recall bias and social desirability bias. Second, the study is geographically restricted to Aba South LGA, and findings may not be fully representative of the adolescent healthcare utilisation experience across all of Abia State. However, efforts were made to ensure the sample was representative of the LGA through rigorous multi-stage sampling. Third, some younger respondents required enumerator assistance, which may have introduced some degree of interviewer bias. Enumerators were trained to minimise this risk by strictly following the questionnaire format. Despite these limitations, the study is considered sufficiently rigorous to generate valid and reliable insights into the subject matter.

1.9 Definition of Key Terms

Adolescents: Individuals between the ages of 10 and 19 years as defined by the World Health Organization (WHO, 2021), subdivided into early (10–13 years), middle (14–16 years), and late adolescence (17–19 years).

Public Healthcare Services: Health services provided by government-owned or government-operated facilities at the primary, secondary, and tertiary levels, including PHC centres, general hospitals, and community health posts.

Healthcare Utilisation: The frequency and pattern with which individuals seek and use available healthcare services, including preventive, curative, promotive, and rehabilitative services.

Socioeconomic Determinants: The social and economic conditions that influence the health-seeking behaviour and healthcare utilisation of individuals and populations, including income level, educational attainment, occupation, social status, and access to resources.

Household Income: The total gross income received by all members of a household over a specified period, used as a proxy for economic status and ability to pay for healthcare.

Health Insurance: A mechanism for pre-paying for healthcare costs, enabling individuals to access health services without the immediate burden of out-of-pocket payment.

Out-of-Pocket (OOP) Expenditure: Direct payments made by individuals or households to healthcare providers at the time of service, without the benefit of pre-payment through insurance.

Health-seeking Behaviour: The actions taken by individuals who perceive themselves to be ill or in need of healthcare, with the aim of finding an appropriate remedy or treatment.