Apart from the morbidity and mortality, the Coronavirus disease 2019 (COVID-19) pandemic has increased the predisposition of households in Nigeria to forgone care, thereby increasing their vulnerability to adverse health consequences. Since there is no previous study in Nigeria on the evolution of pandemic-related forgone care and its drivers, our study assess the evolution of the problem using descriptive and nationally representative panel data analyses. We found about a 30% prevalence of forgone care during the lockdown, which declined progressively afterwards, dropping by 69.50 percentage points between April 2020 and April 2022. This decline produced a surge in households needing care from about 35.00% in the early pandemic to greater than 50%, beginning in early 2021. The forgone care was primarily due to financial hindrances, movement restrictions, and supply-side disruptions. Household socioeconomic factors such as income loss had 2.74 [95%CI: 1.45–5.17] times higher odds of forgone care, job loss, food insecurity, and poverty were 87% (OR: 1.87 [95%CI: 1.25–2.79]), 60% (OR: 1.60 [95%CI: 1.12–2.31]) and 76% (OR: 1.76 [95%CI: 1.12–2.75]) more likely to predispose households to forgone care, respectively. Also, geographical location, such as the South-South zone, induced 1.98 [95%CI: 1.09–3.58] times higher odds of forgone care than North-Central. A married female household head increased the odds by 6.07 [95%CI: 1.72–21.47] times compared with an unmarried female head. However, having a married household head, social assistance, and North-East or North-West zone compared with North-Central increased the chance of accessing care by 69% (OR 0.31 [95%CI: 0.16–0.59]), 59%,(OR 0.41 [95%CI: 0.21–0.77]), 72% (OR 0.28 [95%CI: 0.15–0.53]) and 64% (OR 0.36 [95%CI: 0.20–0.65]), respectively. Non-communicable diseases, disability, old age, large household size and rural-urban location did not affect the forgone care. Our study highlights the need to strengthen Nigeria's health system, create policies to promote healthcare accessibility and prepare the country for future pandemic challenges.
In recent history, only a few events have been able to produce as much global socioeconomic disruption and devastation as the Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus infection. Apart from the disease burden, the COVID-19 pandemic has worsened the pre-existing inequalities in health access and detrimental health outcomes in most countries [[
Nigeria was leading in the prevalence of pandemic-induced forgone care and its adverse consequences in SSA [[
Considering the severe implications of forgone care on health outcomes, studies on the prevalence of forgone care in Nigeria are pertinent. However, only a handful of literature has attempted to provide an overview of healthcare service disruption or forgone care in Nigeria [[
To explore the factors driving household forgone care during the pandemic, we developed a triangular conceptual framework for the determinants of healthcare utilisation documented in the literature (Fig 1). There are two categories of factors: Extrinsic (outside the triangle) and Intrinsic factors (inside the triangle). There are three extrinsic factors, which are outside the immediate environment of a household, that interplayed during the pandemic. They include the number of COVID-19 cases, government mobility restriction policy and supply of health services. These three factors existed in a vicious circle, one influencing the other. We examined these extrinsic factors descriptively (i.e. reasons for forgoing care). Three categories of intrinsic factors are outplayed within a household, making it vulnerable to forgone care. Individual household factors were adapted from the three classical factors of Andersen's Behavioural Model of Health Service Utilization (BMHSU): predisposing, enabling (or disabling) and need factors [[
Graph: Notes: The conceptual framework shows three extrinsic factors (outside the triangle) and three intrinsic factors (inside the triangle). The extrinsic factors are those induced by the pandemic and operate outside the immediate environment of a household. They include the number of COVID-19 cases, government mobility restriction policy and disruption in the supply of health services. They exist in a vicious circle. The Intrinsic factors are those that operate within a household even before the pandemic. The Individual household factors were adapted from the three classical factors of Andersen's Behavioural Model of Health Service Utilization (BMHSU) and included predisposing, enabling (or disabling) and need factors [[
Since household decision-making primarily lies with the household head, the predisposing factors are socio-demographic and health beliefs of the household head, such as age, gender, marital status, and education (including health literacy). The enabling (or disenabling) factors are resources necessary for accessing care (e.g., household finance, number of working adults, health insurance, and adult-equivalent household size). The need factors include household actual or diagnosed or perceived health status of the household members (e.g., presence of chronic diseases or elderly). The remaining two intrinsic factors are elements in the milieu where a household is located. This part of our model was inspired by the work of Ryvicker (2018) [[
We conducted a longitudinal study using three sets of nationally representative panel data collected between 2019 and 2022 by the Nigeria National Bureau of Statistics (NBS) in collaboration with the World Bank as part of the Living Standard Measurement Studies (LSMS) [[
Considering the difficulty encountered during NLPS-1 in contacting households which provided a reference person's contact, only those that supplied a member's number were contacted in NLPS-2. All 4,440 households that provided at least one member's phone number in GHSP (wave 4) were contacted in NLPS-2. This included 2,701 of 3,000 households that provided a household member's number in the baseline of NLPS-1. With a 65% response rate in the NLPS-1 baseline sample, about 2,900 households were expected to complete the NLPS-2 interview. In round 1, 64.8% (2,922 households) of the 4,440 contacted were fully interviewed (S2 Table). These 2,922 households were the final sample contacted in subsequent rounds of NLPS-2. Our study used four rounds of NLPS-2 which contains health access data (S2 Table).
A balanced sampling method, using the cube method, was adopted to ensure the selected households in NLPS-1 and NLPS-2 retained the properties of the original GHSP frame [[
We analysed data collected over three years, from 2020 to 2022, and divided them, for descriptive purpose, into three distinct non-continuous periods: the peri-outbreak (2020), post-outbreak 1 (2021), and post-outbreak 2 (2022) periods. The peri-outbreak period includes data collected in 2020, specifically the NLPS-1, rounds 1 to 4, collected between April and August 2020. This period captures the lockdown period in April-May 2020 to the peak of the pandemic's first wave in June 2020 (see S1 Fig, Lower Panel) and immediately after (Fig 2). There is no health utilisation data from September to December 2020. The post-outbreak 1 period covers data collected from January 2021 to December 2021, with a gap of seven months between April and October 2021. Most of the third wave of the infection occurred during this interval between NLPS-1 and NPLS-2. The post-outbreak 1 period includes the last three rounds of NLPS-1 (rounds 9 to 11) and part of the first round of NLPS-2, collected between November and December 2021 (S1 and S2 Tables). This period mainly telescopes the peak of the second wave in January 2021 (see S1 Fig, Lower Panel) and immediately after. The post-outbreak 2 period covers 2022 and includes the remaining part of round 1 and rounds 3 to 5 of NLPS-2. Round 2 of NLPS-2 has no health access data. This post-outbreak 2 period mainly spans from the peak of the third wave in January 2022 to the fourth wave, which began in June 2022 (see S1 Fig, Lower Panel). Except the baseline round of NLPS-1 which used a 4-week recall, all rounds used a seven-day recall period for data collection. The three-point timeline we used provides an opportunity to compare forgone care during the peaks of the pandemic's waves (S1 Fig, Lower Panel) and between similar periods during the three years of the pandemic in Nigeria, accounting for seasonal variations.
Graph: Notes: Peri-outbreak represents a period from April to August 2020. Post-outbreak 1 and 2 represent a period from January 2021 to December 2021, with some gaps from April to October 2021 and January to August 2022, respectively. NLPS-1 and NLPS-2 represent Nigeria COVID-19 National Longitudinal Phone Surveys phase 1 and phase 2 respectively.
Forgone care is our outcome variable for this study. A household is considered to have forgone care when they reported needing care but could not access it. We measured forgone care using healthcare access questions in our surveys. The surveys asked two nested questions inquiring about household access to healthcare services: (
We examine the variability of the above outcomes (forgone care) with time. The survey also asked why people could not assess care in the form of an open-ended question. We matched each care forgone with those reasons given and assessed the trend over time. We categorised the reasons into five as follows: (
We used descriptive statistics to assess the distribution and prevalence of forgone care, expressing categorical variables as counts or percentages. The prevalence of forgone care is the proportion of households who reported needing care but could not access the care. We reported our findings with their 95% confidence intervals (95% CIs).
To further understand the dynamics of forgone care during the pandemic, we estimated the pull prevalence across the rounds and data collection timeline. We performed a time-trend analysis of the prevalence of forgone medical care, comparing it with the trend in COVID-19 cases, deaths and Oxford Stringency Index (OSI), using data obtained from Our World in Data [[
To explore the intrinsic determinants of household vulnerability to forgone care during the pandemic, we constructed a panel between all the eleven rounds of NLPS used in this study and employed random effects estimator, confirmed by Hausman's specification test [[
Graph
Where y
All statistical analyses were performed using Stata/MP 17 (StataCorp, Texas, USA) for Windows. In our analysis of the evolution of forgone care, we applied survey weights disseminated with the datasets to obtain nationally representative estimates. The NLPS-1 and NLPS-2 survey weights were built on the sampling weights of the parent GHSP survey, using well-established methods detailed elsewhere [[
This study used fully anonymised secondary data collected by NBS and repository at the online Word Bank microdata page, accessed from March, 2021 to March 2023. Ethical approval for this research was waived by the Murdoch University Human Research Ethics Committee (project approval reference number 2022/159).
Table 1 compares household characteristics in the survey rounds in the periods before and after the COVID-19 outbreak. Most household characteristics spanning the four years were essentially unchanged. Majority of households (61.80% [95%CI: 58.04–69.29]) in the sample were in the rural area. Most of the household heads (79.88% [95%CI: 78.74–80.97]) were male, and 74% [95%CI: 72.76–75.20] of them were married. A majority (63.08% [(95%CI: 61.7–64.41]) of the household heads had some form of formal education. Before the outbreak, about 40.11% [95%CI: 38.76–41.48] of the households were below the national poverty line, and 12.99% [95%CI: 12.09–13.95] had persons with NCDs.
Graph
Table 1 Household sample composition in the rounds of the surveys in the year before (2019) and the three years after the outbreak of Covid-19 in Nigeria (2020–2022).
Household Characteristicsα Survey Roundsβ Household's geopolitical zone 0 1 2 3 4 9 10 11 13 15 16 17 North-Central 845 (15.28) [14.02–16.63] 331 (15.28) [13.22–17.59] 299 (15.28) [13.09–17.75] 287 (15.28) [13.07–17.78] 295 (15.28) [13.10–17.175] 276 (15.28) [13.05–17.82] 274 (15.28) [13.06–17.79] 274 (15.28) [13.04–17.83] 758 (15.28) [13.51–17.23] 497 (15.28) [13.39–17.37] 495 (15.28) [13.42–17.35] 219 (15.28) [13.37–17.41] North-East 825 (11.14) [10.04–12.35] 331 (11.14) [9.45–13.09] 317 (11.14) [9.41–13.15] 321 (11.14) [9.43–13.12] 319 (11.14) [9.41–13.14] 312 (11.15) [9.40–13.17] 312 (11.14) [9.40–13.16] 307 (11.15) [9.37–13.21] 692 (11.14) [9.63–12.85] 484 (11.14) [9.58–12.92] 483 (11.14) [9.57–12.93] 295 (11.14) [9.54–12.97] North-West 843 (22.78) [21.09–24.57] 308 (22.78) [19.97–25.86] 294 (22.78) [19.92–25.91] 286 (22.78) [19.89–25.95] 278 (22.78) [19.84–26.01] 271 (22.79) [19.84–26.03] 270 (22.78) [19.81–26.05] 265 (22.79) [19.80–26.08] 693 (22.78) [20.29–25.47] 394 (22.78) [20.20–25.58] 389 (22.78) [20.18–25.61] 230 (22.78) [20.08–25.72] South-East 824 (15.54) [14.30–16.87] 366 (15.54) [13.60–17.71] 330 (15.54) [13.56–17.76] 327 (15.54) [13.50–17.83] 326 (15.54) [13.50–17.83] 308 (15.51) [13.44–17.82] 307 (15.54) [13.43–17.92] 305 (15.51) [13.41–17.86] 777 (15.54) [13.94–17.30] 505 (15.54) [13.89–17.36] 502 (15.54) [13.83–17.43] 252 (15.54) [13.80–17.46] South-South 815 (17.74) [16.27–19.32] 295 (17.74) [15.35–20.42] 245 (17.74) [15.21–20.59] 238 (17.74) [15.15–20.67] 238 (17.74) [15.17–20.65] 214 (17.75) [15.09–20.76] 218 (17.74) [15.11–20.73] 213 (17.75) [15.07–20.79] 744 (17.74) [15.74–19.94] 422 (17.74) [15.59–20.12] 411 (17.74) [15.59–20.13] 131 17.74 [15.54–20.19] South-West 824 (17.52) [15.87–19.29] 384 (17.52) [14.93–20.44] 345 (17.52) [14.84–20.57] 349 (17.52) [14.86–20.24] 342 (17.52) [14.86–20.55] 325 (17.52) [14.81–20.61] 327 (17.52) [14.82–20.58] 325 (17.52) [14.83–20.60] 776 (17.52) [15.42–19.84] 579 (17.52) [15.36–19.91] 572 (17.52) [15.31–19.97] 176 (17.52) [15.28–20.00] Household's location Urban 1,592 (31.44) [29.58–33.36] 774 (31.44) [28.57–34.46] 719 (31.44) [28.47–34.56] 710 (31.44) [28.45–34.59] 707 (31.44) [38.44–34.60] 668 (31.43) [28.38–34.62] 668 (31.44) [38.38–34.67] 666 (31.43) [38.35–34.68] 1,533 (31.44) [28.99–33.99] 1,157 (31.44) [28.93–34.06] 1,141 (31.44) [28.87–34.13] 491 (31.44) [28.83–34.17] Rural 3,384 (68.56) [66.64–70.42] 1,241 (68.56) [65.54–71.43] 1,111 (68.56) [65.44–71.53] 1,098 (68.56) [65.41–71.55] 1,091 (68.56) [65.40–71.56] 1,038 (68.57) [65.35–71.62] 1,040 (68.56) [65.33–71.62] 1,023 (68.57) [65.32–71.65] 2,907 (68.56) [66.01–71.01] 1,724 (68.56) [65.94–71.07] 1,711 (68.56) [65.87–71.13] 812 (68.56) [65.83–71.17] Household size (category) Less than seven 3,523 (68.43) [66.54–70.26] 1,259 (60.70) [57.47–63.85] 1,125 (60.06) [56.70–63.32] 1,095 (58.92) [55.52–62.24] 1,077 (58.37) [54.93–61.72] 932 (52.82) [49.31–56.31] 926 (52.64) [49.13–56.13] 911 (51.87) [48.29–55.35] 1,676 (53.28) [50.51–56.03] 1,556 (54.54) [51.63–57.42] 1,489 (53.78) [50.83–56.70] 651 (53.52) [50.50–56.52] More than seven 1,457 (31.57) [29.74–33.46] 751 (39.30) [36.15–42.53] 705 (39.94) [36.68–43.30] 712 (41.08) [37.76–44.48] 721 (41.63) [38.28–45.07] 774 (47.18) [43.69–50.69] 779 (47.36) [43.87–50.87] 777 (48.17) [44.65–51.71] 1,303 (46.72) [43.97–49.49] 1,113 (45.46) [42.58–48.37] 1,123 (46.22) [43.30–49.17] 652 (46.48) [43.48–59.50] NCD-affected households (pre-pandemic) Not NCD-affected 4,333 (87.76) [86.46–88.95] 1,739 (87.47) [85.28–89.37] 1,579 (87.66) [85.37–89.63] 1,562 (87.46) [85.13–89.47] 1,552 (87.70) [85.44–89.65] 1,465 (87.13) [84.78–89.17] 1,468 (87.07) [84.67–89.15] 1,453 (87.22) [84.83–89.28] 3,861 (87.57) [85.64–89.27] 2,505 (87.58) [85.58–89.34] 2,476 (87.96) [86.01–89.67] 1,102 (87.39) [85.28–89.24] NCD-affected 647 (12.24) [12.05–13.54] 276 (12.53) [10.63–14.72] 251 (12.34) [10.37–14.63] 246 (12.54) [10.53–1.87] 246 (12.30) [10.35–14.56] 241 (12.87) [10.83–15.22] 240 (14.05) [12.48–15.78] 236 (12.78) [10.72–15.17] 579 (12.43) [10.73–14.36] 376 (12.42) [10.66–14.42] 376 (12.04) [10.33–13.99] 201 (12.61) [10.76–14.72] Poor Households (pre-pandemic) No 2,980 (61.15) [59.22–63.06] 1,303 (61.24) [57.97–64.41] 1,188 (61.10) [57.70–64.40] 1,173 (61.04) [57.61–64.37] 1,161 (61.06) [57.60–64.41] 1,097 (60.91) [57.40–64.31] 1,100 (60.82) [57.31–64.21] 1,095 (60.67) [57.13–64.10] 2,751 (61.17) [58.41–63.87] 1,880 (61.34) [58.43–64.17] 1,856 (61.34) [58.41–64.20] 821 (61.56) [58.53–64.49] Yes 1,996 (38.85) [36.94–40.78] 712 (38.76) [35.59–42.03] 642 (38.90) [35.60–42.30] 635 (38.96) [35.63–42.39] 637 (38.94) [35.59–42.40] 609 (39.09) [35.69–42.60] 608 (39.18) [35.79–42.69] 594 (39.33) [35.90–42.87] 1,689 (38.83) [36.13–41.59] 1,001 (38.66) [35.83–41.57] 996 (38.66) [35.80–41.59] 482 (38.44) [35.51–41.47] Age of household head (category) 18–34 years 820 (17.14) [15.67–18.71] 268 (13.28) [11.25–15.62] 263 (14.14) [12.87–16.61] 263 (14.24) [12.07–16.72] 260 (14.15) [11.99–16.62] 234 (13.29) [11.16–15.76] 231 (13.61) [11.42–16.13] 234 (13.50) [11.32–16.02] 352 (13.19) [11.36–15.25] 299 (12.63) [10.78–14.73] 288 (12.59) [10.72–14.74] 133 (12.51) [10.61–14.69] 35–49 years 1,745 (37.53) [35.59–39.52] 745 (39.05) [35.84–42.35] 681 (37.94) [34.67–41.33] 670 (38.74) [35.40–42.20] 669 (39.55) [36.18–43.02] 642 (39.57) [36.14–43.10] 647 (39.64) [36.22–43.17] 638 (40.06) [36.60–43.62] 1,089 (38.51) [35.82–41.27] 1,008 (38.83) [36.01–41.74] 992 (38.76) [35.91–41.70] 525 (38.96) [36.02–41.99] 50–64 years 1,467 (28.15) [26.44–29.93] 611 (29.85) [26.98–32.89] 564 (30.18) [27.16–33.38] 559 (29.46) [26.49–32.62] 559 28.80) [25.87–31.91] 527 (29.27) [36.14–43.10] 525 (28.89) [25.89–32.09] 516 (29.90) [25.87–32.12] 958 (29.81) [27.40–32.33] 863 (30.60) [28.05–33.27] 852 (30.44) [27.87–33.13] 418 (30.95) [28.32–33.71] 65 years or more 948 (17.18) [15.80–18.65] 359 (18.10) [16.47–19.86] 317 (17.74) [15.30–20.48] 309 (17.55) [15.06–20.36] 305 (17.50) [15.02–20.29] 301 (17.87) [15.34–20.71] 300 (17.86) [15.35–20.69] 294 (17.54) [15.07–20.32] 577 (18.50) [16.53–20.64] 499 (17.95) [15.91–20.17] 480 (18.21) [16.13–20.49 227 (17.57) [15.49–19.87] Marital status of household head Married 3,685 (74.96) [73.18–76.66] 1,513 (74.96) [71.99–77.71] 1,379 (75.00) [71.95–77.83] 1,366 (75.06) [71.95–77.93] 1,360 (75.04) [71.92–77.91] 1,300 (74.79) [71.60–77.74] 1,296 (74.64) [71.43–77.60] 1,285 (74.70) [71.47–77.69] 3,324 (74.49) [72.02–76.81] 2,224 (74.53) [71.93–76.96] 2,201 (74.53) [71.92–76.97] 1,052 (74.52) [71.87–77.01] Unmarried 1,295 (25.04) [23.34–26.82] 501 (25.04) [22.29–28.01] 450 (25.00) [22.17–28.05] 441 (24.94) [22.07–28.93] 437 (24.96) [22.09–28.08] 405 (25.21) [22.26–28.40 411 (25.36) 22.40–28.57] 403 (25.30) [22.32–28.53] 1,114 (25.51) [23.19–27.98] 656 (25.47) [23.04–28.07] 650 (25.47) [23.03–28.08] 250 (25.48) [22.99–28.13] Education level of household head None 1,837 (37.84) [35.93–39.78] 571 (37.15) [33.94–40.48] 512 (37.42) [34.08–40.87] 493 (36.85) [33.48–40.35] 487 (37.07) [33.68–40.60] 467 (36.99) [33.57–29.54] 475 (37.27) [33.85–40.83] 463 (37.28) [33.83–40.87] 1,438 (37.76) [35.06–40.54] 786 (37.76) [34.91–40.69] 782 (37.39) [34.54–40.34] 351 (37.13) [34.21–40.15] Primary 1,219 (23.94) [22.31–25.64] 507 (23.88) [21.26–26.71] 449 (23.37) [20.68–26.31] 453 (23.83) [21.11–26.77] 449 (23.57) [20.86–26.52] 423 (23.66) [20.89–26.69] 417 (23.27) [33.85–40.24] 412 (23.14) [20.37–26.15] 1,129 (23.51) [21.29–25.88] 719 (23.77) [21.45–26.27] 713 (23.84) [21.48–26.38] 313 (24.24) [21.78–26.87] Secondary 1,095 (22.42) [20.74–24.19] 511 (23.17) [20.51–26.06] 466 (23.44) [20.68–26.45] 464 (23.55) [20.76–26.59] 460 (23.58) [20.80–26.61] 443 (23.56) [20.972–26.65] 437 (23.69) [20.84 26.81] 441 (23.80) [20.94–26.93] 1,056 (22.90) [20.68–25.29] 750 (22.66) [20.34–25.17] 743 (22.96) [20.59–25.50] 329 (22.86) [20.45–25.46] Tertiary 825 (15.81) [14.46–17.27] 426 (15.80) [13.83–17.99] 403 (15.77) [13.73–18.03] 398 (15.77) [13.71–18.08] 402 (15.78) [13.72–18.08] 373 (15.79) [13.64–18.20] 379 (15.80) [13.68–18.19] 373 (15.78) [13.61–18.21] 817 (15.83) [14.04–17.79] 626 (15.80) [13.99–17.81] 614 (15.81) [13.95–17.86] 310 (15.78) [13.89–17.87] Sex of household head Female 1,002 (18.63) [17.15–20.21] 365 (17.87) [15.54–20.47] 338 (18.52) [15.90–20.96] 329 (18.16) [15.72–20.89] 329 (18.34) [15.88–21.08] 302 (19.17) [16.54–22.11] 306 (18.94) [16.35–21.84] 296 (18.45) [15.91–21.29] 544 (18.97) [16.97–21.15] 492 (19.06) [16.97–21.35] 480 (19.45) [1.30–21.78] 217 (19.18) [17.01–21.55] Male 3,978 (81.37) [79.79–82.85] 1,619 (82.13) [79.53–84.46] 1,487 (81.71) [79.40–84.10] 1,472 (81.84 [79.1–84.28] 1,464 (81.66) [78.92–84.12] 1,402 (80.83) [77.89–83.46] 1,397 (81.06) [78.16–83.65] 1,386 (81.55) [78.71–84.09] 2,432 (81.03) [78.85–83.03] 2,177 (80.94) [78.65–83.03] 2,132 (80.55) [78.22–82.70] 1,086 (80.82) [78.45–82.99] Household in need of medical care No 1,475 (30.26) [28.46–32.13] 1,326 (65.73) [62.51–68.80] 1,225 (64.87) [61.52–68.08] 1,107 (60.26) [56.89–63.54] 1,095 (58.76) [55.32–62.14] 788 (46.18) [42.71–49.69] 958 (54.52) [51.00–57.99] 905 (54.05) [50.52–57.54] 1,525 (51.16) [48.40–53.92] 1,503 (54.61) [51.70–57.48] 1,242 (47.21) [44.30–50.14] 1,260 (47.91) [44.93–50.91] Yes 3,504 (69.74) [67.87–71.54] 651 (34.27) [31.20–37.49] 602 (35.13) [31.92–38.48] 695 (39.54) [36.46–43.11] 702 41.24) [37.86–44.69] 918 (53.82) [50.31–57.29] 745 (45.48) [42.01–49.00] 780 (45.95) [42.46–49.48] 1,433 (48.84) [46.08–51.60] 1,162 (45.39) [42.52–48.30] 1,368 (52.79) [49.86–55.70] 1,318 (52.09) [49.09–55.07] Household with forgone medical care No 2,901 (83.36) [81.48–85.09] 493 (74.41) [69.11–79.08] 528 (85.63) [80.70–89.47] 602 (86.39) [82.33–89.63] 637 (89.88) [85.66–92.96] 810 (86.87) [83.18–89.85] 699 (93.53) [90.39–95.69] 745 (96.40) [94.46–97.68] 1,354 (94.08) [91.89–95.70] 1,138 (97.23) [95.03–98.47] 1,337 (93.32) [93.8–97.81] 1,295 (97.54) [95.37–98.70] Yes 603 (16.64) [14.91–18.52] 157 (25.59) [20.92–30.89] 74 (14.37) [10.53–19.30] 93 (13.61) [10.37–17.68] 65 (10.12) [7.04–14.34] 108 (13.13) [10.15–16.82] 46 (6.47) [4.31–9.61] 35 (3.60) [2.32–5.54] 79 (5.92) [4.30–8.11] 23 (2.77) [1.53–4.97] 31 (3.68) [2.19–6.12] 23 (2.46) [1.30–4.63]
1 Notes:
- 2
β The GHSP pre-pandemic round is recorded as 0, and to form a continuous round, rounds 1, 3, 4 and 5 of the NLPS-2 are represented respectively as rounds 13, 15, 16 and 17, respectively. - 3 95% CIs are shown in square brackets.
Table 1 also shows heterogeneity in needed and forgone care of households across the years of the surveys. The distribution of households' need for medical care during the pandemic is shown in Fig 3. The average proportion of households that needed care during the three years of the pandemic was 44.98% [95%CI: 44.00–45.95] (Table 1). The proportion of households requiring care was stable at around 35% during the first three months, an half of the pre-pandemic level (70.38% [95%CI: 69.09–71.63]). However, the number began to rise around July 2020 and, in most cases, was above the peri-outbreak figure, exceeding 50% in early 2021 (post-outbreak 1) and late 2022 (post-outbreak 2). The prevalence was still lower than the pre-pandemic level.
Graph: Notes: authors' calculations were based on weighted samples of Nigeria COVID-19 National longitudinal phone surveys (NLPS) 2020/2021 (rounds 1, 2, 3, 4, 9, 10 and 11) and 2021/2022 (rounds 1, 3,4 and 5). Peri-outbreak represents a period from April to August 2020. Post-outbreak 1 and 2 represent a period from January 2021 to December 2021, with some gaps from April to October 2021 and January to August 2022, respectively.
Fig 4 shows the proportion of forgone care was about 30.00% in April 2020. However, the proportion began to drop as the pandemic progressed, giving an increase in access by approximately 69.50 percentage points between April 2020 and April 2022. The improvement in medical access was only slightly interrupted around Jan 2021, with a fall of 3.10 percentage points in access, compared with August 2020 and almost at par with June/July 2020 prevalence.
Graph: Notes: The table shows the distribution of household access to medical services during the pandemic. With variability, more households could access care than forgone care, even during the early pandemic. The proportion of forgone care was highest in April 2020 and dropped progressively thereafter. Authors' calculations were based on weighted samples of Nigeria's COVID-19 National longitudinal phone surveys (NLPS) 2020/2021 (rounds 1, 2, 3, 4, 9, 10 and 11) and 2021/2022 (rounds 1, 3,4 and 5). Peri-outbreak represents a period from April to August 2020. Post-outbreak 1 and 2 depict a period from January 2021 to December 2021, with some gaps from April to October 2021 and January to August 2022, respectively.
The prevalence of forgone care decreased over time, with the highest prevalence occurring during the lockdown period in April/May 2020 at almost 30.00% (Fig 4). The mean prevalence during the peri-outbreak period was 15.56% [95%CI: 13.49–17.63], representing about 6.3 million [95%CI: 5.50–7.10] households (S3 Table). The prevalence continued to fall during consecutive periods with averages of 7.38% [95% CI: 6.09–8.66] and 2.63% [95% CI: 1.71–3.56] during the "post-outbreak 1" and "post-outbreak 2" periods, respectively. The trend in forgone care appears to respond to the number of COVID-19 cases and deaths and the stringency of measures put in place to control the virus (S1 Fig). The highest prevalence of forgone care occurred during the lockdown period, and the overall trend continued to fall after, with three other lower peaks around July-August 2020, January-February 2021 and December 2021- January 2022. These appear to follow the volume and spikes in the number of COVID-19 cases and deaths, though not proportionately than the stringency index (S1 Fig).
Fig 5 and S2 Fig depict the decline in essential services sought during the early stages of the pandemic. The highest proportion of forgone care was observed for child vaccination (21.00%), followed by medicine (12.70%) and appointments (outpatient consultation) (9.60%). In contrast, the least forgone care was for maternal health/pregnancy care (5.20%). The trend for forgone care for these three essential services showed a similar reduction after the initial period, but with some variability, as shown in S2 Fig. Access to child vaccination, medicine, and maternal health/pregnancy care improved after January 2021, albeit with some interruptions between December 2021 and March 2022 for child vaccination and medicine, and between November and December 2021 for maternal/pregnancy care. As a result, the proportion of forgone care for maternal/pregnancy care reached its highest level at 14.40% during this period.
Graph: Notes: authors' calculations were based on weighted samples of Nigeria COVID-19 National longitudinal phone surveys (NLPS) 2020/2021 (rounds 1, 2, 3, 4, 9, 10 and 11) and 2021/2022 (rounds 1, 3,4 and 5).
Fig 6 and S3 Fig show the reasons given by the households for forging medical care in general. Financial hindrances topped the list throughout the period examined, with a mean prevalence of 74.51% [95%CI: 69.71–78.79]. It continued to increase relative to other reasons after April/May 2020. Supply-side disruption was next to financial reasons (11.90% [95%CI: 8.98–15.61]) and persisted throughout the periods of the pandemic, more prominently in the post-outbreak 2. Mobility restriction was prominent in the early pandemic, ranking next to financial reasons with a prevalence of 23.77% [95%CI: 15.35–34.91] in April/May 2020; it became inconsequential after June 2020. The fear of COVID-19 constituted the least important reason for forgone care (with a mean prevalence of 5.66% [95%CI: 3.66–8.65] and ceased becoming an issue outside the peri-outbreak period. Supply-side and other reasons gradually displaced COVID-19 concerns and mobility restrictions in the post-outbreak periods with a mean prevalence of 19.41% [95%CI: 11.79–30.26] and 10.05% [95%CI: 4.34–21.60], respectively between January and August 2022.
Graph: Notes: The figure shows variability in the reasons households forgone care. Financial hindrances constitute the highest percentage throughout the pandemic. In the early pandemic, mobility restriction was next to financial hindrance, but was replaced by supply-side disruption later in the pandemic. The fear of COVID-19 constituted the least important reason for forgone care, especially beyond peri-outbreak period. Authors' estimates were based on weighted samples of Nigeria's COVID-19 National longitudinal phone surveys (NLPS) 2020/2021 (rounds 1, 2, 3, 4, 9, 10 and 11) and 2021/2022 (rounds 1, 3,4 and 5). Peri-outbreak represents a period from April to August 2020. Post-outbreak 1 and 2 depict a period from January 2021 to December 2021, with some gaps from April to October 2021 and January to August 2022, respectively.
The reasons cited for forgoing different types of essential services also varied (S4 Table). Except for child vaccination, financial hindrance was the most frequently cited reason for forgoing care, with prevalence of 48.56% [95%CI: 27.86–69.77] for maternal health/pregnancy care and 79.03% [95%CI: 67.96–87.01] for medicine. Supply-side disruption (43.09% [95%CI: 31.77–55.18]) and mobility restrictions (35.96% [95%CI: 26.23–46.99]) were the main reasons for households forgoing child vaccination.
Table 2 shows the results of the panel logistic regression for the determinants of household forgone care during the pandemic. Four household factors significantly impacted household forgone care during the lockdown period and throughout the pandemic. Household income loss significantly increased the odds of having forgone care by 2.23 [95%CI: 1.00–4.99], p<0.05 during the lockdown and 2.74 [95%CI: 1.45–5.17], p<0.01 for the whole duration of the pandemic compared with households with either stable or increased income. However, compared with households in the North-Central, households in the North-East were 75.00% (OR 0.25 [95%CI: 0.15–0.58]) and 72.00% (OR 0.28 [95%CI: 0.15–0.53]) significantly less likely (p<0.01) to experience forgone during the lockdown and the duration of the pandemic, respectively. Similarly, households in the North-West zones compared with North-Central were 70.00% (OR 0.30 [95%CI: 0.15–0.58]) and 64.00% (OR 0.36 [95%CI: 0.20–0.65]) significantly less likely (p<0.01) to experience forgone care during the lockdown and through the pandemic, respectively. Households with a married head compared with an unmarried/divorced household head were 70.00% (OR 0.30 [0.14–0.62]) and 69.00% (OR 0.31 [95%CI: 0.16–0.59]) significantly less likely (p<0.01) to experience forgone care during the lockdown and throughout the pandemic, respectively.
Graph
Table 2 Determinants of household vulnerability to forgone care during the pandemic in Nigeria (2020–2022) (Panel data logistic regression with random effect estimator).
Explanatory Variable During the Pandemic Period Lockdown Period Subsample Odd Ratio Odd Ratio Predisposing factors Age of household head 0.94 [0.88–1.02] 0.96 [0.88–1.05] Age squared 1.00 1.00 [1.00–1.00] Female household head 0.59 [0.28–1.26] 0.56 [0.25–1.24] Married household head 0.31 0.30 Married female household head 6.07 6.25* [0.97–40.27] Literacy of household head 1.005 [0.63–1.61] 0.927 [0.57–1.51] Enabling (or disenabling) factors Household size 0.98 [0.93–1.04] 0.96 [0.88–1.03] Household with income loss 2.74 2.23 Household that received assistance 0.73 [0.41–1.28] 0.41 Job loss by respondent (Previously working) 1.87 1.02 [0.68–1.52] Poor household (pre-pandemic) 1.76 1.22 [0.76–1.96] Household with food insecurity 1.60 1.39 [0.88–2.19] Need factors Household member with a disability (pre-pandemic) 1.34 [0.82–2.19] 1.36 [0.80–2.33] NCD-affected household (pre-pandemic) 1.10 [0.66–1.81] 1.06 [0.61–1.85] Household with an elderly member 0.77 [0.45–1.34] 0.83 [0.45–1.53] Environmental factors Rural location 0.85 [0.54–1.32] 0.86 [0.53–1.42] North-Central Zone Reference Reference North-East Zone 0.28 0.25 North-West Zone 0.36 0.30 South-East Zone 1.04 [0.55–1.96] 1.01 [0.51–1.98] South-South Zone 1.98 1.29 [0.63–2.62] South-West Zone 0.84 [0.44–1.62] 0.54 Constant 0.58 [0.07–4.56] 2.17 [0.20–3.29] Number of observations 1,335 638 Number of households 1,026 638
- 4 Note: Authors' estimates were based on unweighted samples of Nigeria's COVID-19 National longitudinal phone surveys (NLPS) 2020/2021 (rounds 1, 2, 3, 4, 9, 10 and 11) and 2021/2022 (rounds 1, 3,4 and 5).
- 5
α Regression performed on rounds 1 and 2 sub-sample, covering only the Lockdown period (April-June 2020). - 6
β Square of the age of household head included in the regression. - 7
¶ Households with a reduction in income compared with the same month in the preceding year - 8
φ Households below the national poverty line pre-pandemic. - 9
§ Measured by any adult that went without eating for a whole day in the past week. - 10 P values: *** p<0.01
- 11 ** p<0.05
- 12 * p<0.1
- 13 95% CIs are shown in square brackets.
- 14 Robust standard errors clustered at the enumeration area (EA).
Although not statistically significant, a household with a female head was 41% (OR 0.59 [95%CI: 0.28–1.26]) less likely to experience forgone care than a male-headed household. However, being a married female household head increased the odds of household forgone care by 6.07 [95%CI: 1.72–21.47], p<0.01 during the pandemic compared to the unmarried female household head.
For socioeconomic conditions, the odds of a household incurring a forgone care became significantly larger as the pandemic progressed. While households below the poverty line and those with food insecurity did not experience forgone care during the lockdown, they were 76% (OR 1.76 [95%CI: 1.12–2.75]) and 60% (OR 1.60 [95%CI: 1.12–2.31]), receptively more likely to experience forgone care (p< 0.05) as the pandemic progressed. This is similar for job loss with no significant impact on forgone care during the lockdown but was 87% (OR 1.87 [95%CI: 1.25–2.79]), p<0.01, more likely to induce forgone care as the pandemic progressed, compared with households without job loss. However, when compared with households without assistance, households that received assistance were 59% less likely to experience forgone care (OR 0.41 [95%CI: 0.21–0.77]), p<0.05, and this was only during the lockdown.
Apart from households in the South-South which had twice higher (OR 1.98 [95%CI: 1.09–3.58]), p<0.05 likelihood of inducing forgone care, compared with households in the North-Central, during the lockdown, the impact of the other geopolitical locations was lower during the entire length of the pandemic.
There was no evidence that a household head's age or literacy level significantly affected household forgone care. Household size, rural-urban location, and having a household member with NCDs, disability, or old age also conferred no statistically significant impact on forgone care.
This study examined Nigeria's prevalence and determinants of foregone essential care during the COVID-19 epidemic. In the early stages of the pandemic, over one-third of homes did not receive care. After the lockdown, this high prevalence of households forgoing care declined, but with an increase in the number of households requiring care. Financial constraints, mobility restrictions, and supply-side disruptions accounted for most forgone care. A similar trend and reasons were also observed for individual essential care category. Our findings suggest that household characteristics such as income loss, food insecurity, poverty, location in the South-South zone, and having a married female head increased households' susceptibility to forgone care. In contrast, being a married head of a household, receiving support, and residing in the North-East or North-West zones were protective. Surprisingly, NCDs and disability did not affect forgone care.
The findings in our study align with the studies showing a high prevalence of forgone care during the early pandemic in other regions [[
Our study has demonstrated that childhood vaccination was the most affected during the pandemic. This aligns with numerous findings from various parts of the world [[
Our study also revealed that maternal health/pregnancy care, essential medicine and routine appointments, were also affected with forgone care. The latter two which were markedly affected are crucial for the management of NCDs and other chronic diseases [[
Kakietek et al. (2022) corroborate our findings, showing that financial constraints were the most frequently reported reason for forgone care in Nigeria and LMICs [[
A substantial household pre-pandemic financial susceptibility is plausible, with about 40% of Nigerians below poverty and high catastrophic OOP health spending [[
Other socioeconomic characteristics that increased household susceptibility to financial difficulties, such as loss of income or job and food insecurity, were also associated with a greater likelihood of forgoing care [[
Although the prevalence of forgone care dropped after the lockdown, the large volume of households requiring care this time, which is similar to Hategeka et al. (2021) findings in the Democratic Republic of Congo (DRC), and the rising COVID-19 cases and its sequelae cumulatively impacted the capacity of the fragile and battered Nigeria healthcare system to maintain high-quality care after the lockdown [[
Our findings are consistent with studies showing massive disruption in the supply of health services and its negative impact on forgone care during the pandemic [[
The marital status of the household head seems to lower the possibility of forgone care because marriage provides an avenue for additional emotional and financial support from partners. However, when the married household head was a female, the probability of forgone care increased considerably. A study has associated married women with avoidance of care during the pandemic [[
The geographical location of a household appears to impact forgone care. While living in the South-South increased the odds of forgone care, contrary to expectations, we found that living in the North-East and North-West zones minimised the probability of forgone care. These are three zones ravaged by arms conflicts in Nigeria [[
While chronic conditions such as NCDs, disability and old age have been associated with an increased prevalence of forgone care [[
Some limitations relating to data collection were likely to introduce biases in our study. First, phone surveys usually exclude a portion of the population lacking access to phones and stable networks [[
Our study expanded the literature on access to healthcare during the COVID-19 pandemic, demonstrating that the pandemic widened the pre-existing inequalities in health access. The study underpins the need for policy strengthening social protection systems and financial risk protection to alleviate the impact of household socioeconomic vulnerability. The capacity and resilience of the health system must also be strengthened to mitigate ensuing disruptions in service provision. Moreover, developing policy frameworks fostering teleconsultations and balancing lockdown benefits and healthcare accessibility should be prioritised during future pandemics. However, further work is recommended to quantify the exact impacts of the lockdown and the perceived risk of COVID-19 on forgone care in Nigeria.
S1 Table
The distribution of respondents across the seven rounds of the national longitudinal phone survey (phase 1) 2020/2021 used.
(DOCX)
S2 Table
The distribution of respondents across the three rounds of the national longitudinal phone survey (phase 2) 2021/222 used.
(DOCX)
S3 Table
Prevalence of forgone care and population affected during the three-point periods of the pandemic in Nigeria.
(DOCX)
S4 Table
Reasons for forgone care for different essential care services during early COVID-19 pandemic in Nigeria.
(DOCX)
S1 Fig
Time-Trend Plots of Forgone Care (Upper Panel) Compared to the Number of COVID-19 Cases and Deaths and Stringency Index (Lower Panel) Across Time During the Pandemic in Nigeria (2020–2022).(TIF)
S2 Fig
(a-c): Evolution in the prevalence of medicine, maternal health/pregnancy care and child vaccination services during the COVID-19 pandemic in Nigeria.(TIF)
S3 Fig
Overall prevalence of the reasons for forgone care during the COVID-19 pandemic in Nigeria.
(TIF)
We acknowledge the NBS and the World Bank for providing access to the data used in the study. We also appreciate the invaluable support of Murdoch University in providing the scholarship for the doctoral research of which this study is a part. All the views expressed in this article are those of the authors and do not express an official position of Murdoch University.
By Adelakun Odunyemi; Hamid Sohrabi and Khurshid Alam
Reported by Author; Author; Author