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A Case Study of Primary Healthcare Services in Isu,

Nigeria
Raymond Ogu. Chimezie
Walden University

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 Walden University

College of Health Sciences

This is to certify that the doctoral dissertation by

Raymond Chimezie

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by
the review committee have been made.

Review Committee
Dr. Michael Schwab, Committee Chairperson, Public Health Faculty
Dr. Richard Jimenez, Committee Member, Public Health Faculty
Dr. Monica Gordon, University Reviewer, Public Health Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

Walden University
2013
 Abstract

A Case Study of Primary Healthcare Services in Isu, Nigeria

by

Raymond Ogu Chimezie

MA, Argosy University, San Francisco, 2006

HND, Federal Polytechnic, Nekede, 1985

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Public Health: Community Health Education and Promotion

Walden University

April 2013
 Abstract

Access to primary medical care and prevention services in Nigeria is limited, especially

in rural areas, despite national and international efforts to improve health service

delivery. Using a conceptual framework developed by Penchansky and Thomas, this case

study explored the perceptions of community residents and healthcare providers

regarding residents’ access to primary healthcare services in the rural area of Isu. Using a

community-based research approach, semistructured interviews and focus groups were

conducted with 27 participants, including government healthcare administrators, nurses

and midwives, traditional healers, and residents. Data were analyzed using Colaizzi’s 7-

step method for qualitative data analysis. Key findings included that (a) healthcare is

focused on children and pregnant women; (b) healthcare is largely ineffective because of

insufficient funding, misguided leadership, poor system infrastructure, and facility

neglect; (c) residents lack knowledge of and confidence in available primary healthcare

services; (d) residents regularly use traditional healers even though these healers are not

recognized by local government administrators; and (e) residents can be valuable

participants in community-based research. The potential for positive social change

includes improved communication between local government, residents, and traditional

healers, and improved access to healthcare for residents.

A Case Study of Primary Healthcare Services in Isu, Nigeria

by

Raymond Ogu Chimezie

MA, Argosy University, San Francisco, 2006

HND, Federal Polytechnic, Nekede, 1985

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Public Health: Community Health Education and Promotion

Walden University

April 2013
 UMI Number: 3558764

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 Dedication

I dedicate this work to my family for the warm support, prayers, and financial

help they gave to me during these long years of adult learning; to my wife Eunice for her

great understanding and care; to my sons, Chidozie, for his feedback on my initial efforts

of this project, and Chimdike, for his unrelenting prayers to God that I may have the

strength to accomplish this task; to my parents, the late Simon Chimezie and Anthonia

Chimezie, who began this journey for me earlier in my life; to my uncle, the late Chief

Hilary Obiechefu, who always has supported my quests in life and wished that I get a

doctoral degree; to my late father-in-law, Chief Bernard Ogbuji Nwadike, whose

encouraging words will remain with me as long as I live; and to my late uncle, Elder Alex

Asuzuo, who inspired me in the face of great suffering and difficulties. Finally, I dedicate

this work to the people of the Isu Local Government Area and particularly to my own

community, Nnerim Umundugba, for all they have suffered and endured in the face of

neglected healthcare. To those whose lives were cut short by lack of access to

healthcare—I wish that they rest in perfect peace that Christ Jesus gives.
 Acknowledgments

I thank Almighty God for the strength and sustenance both to begin and complete

this study. Without His guidance and assistance, I would not have overcome the great

challenges I faced.

My gratitude goes to my dissertation chair, Dr. Michael Schwab, and my methods

advisor, Dr. Richard Jimenez, for their candid advice and proper guidance to see that I

successfully completed this project. I thank them for their patience and understanding

throughout this process. I also am grateful to the staff of the Isu Local Government Area

and residents of the communities in Isu for their willingness to participate in my study.

I also am grateful to all my fellow doctoral student classmates, in particular Mrs.

Mary Uzochukwu, for all their support and encouragement. I thank all of my friends who

encouraged me to carry on during trying times, especially when I was fell short of my

expectations. My appreciation also goes to my brother-in-law and friend, Mr. Meltus

Nwadike, for his words of encouragement during the trying time in this project.

Finally, I am grateful to Walden University for the opportunity to realize my

dream and for instilling in me the philosophy of social change. I am greatly empowered

by it.
 Table of Contents

List of Tables .................................................................................................................... vii

Chapter 1: Introduction to the Study....................................................................................1

Problem Statement .........................................................................................................3

Purpose of the Study ......................................................................................................4

Conceptual Framework ..................................................................................................4

Nature of the Study ........................................................................................................6

Research Questions ........................................................................................................6

Definition of Terms........................................................................................................8

Assumptions and Limitations ......................................................................................10

Scope and Delimitations ..............................................................................................11

Significance of the Study .............................................................................................12

Summary and Content of the Remaining Chapters......................................................13

Chapter 2: Literature Review .............................................................................................16

Conceptual Framework: A Model of Healthcare Access ............................................17

Traditional Healthcare System in Nigeria....................................................................20

Modern Healthcare Systems ........................................................................................22

International Origins and Scope of Primary Health Care ......................................22

Postcolonial Development in Nigeria ....................................................................29

Healthcare Conditions in Nigeria...........................................................................33

The Importance of Primary Healthcare........................................................................36

Barriers to Healthcare Access ......................................................................................38

i
 Availability ............................................................................................................39

Accessibility...........................................................................................................39

Accommodation .....................................................................................................40

Affordability ..........................................................................................................41

Acceptability ..........................................................................................................43

Community-Based Research as a Potential Tool for Change ......................................43

Literature Related to Methodology and Methods ........................................................45

Qualitative Research Design ..................................................................................45

Case-Study Approach ............................................................................................47

Summary ......................................................................................................................50

Chapter 3: Methodology ....................................................................................................52

Research Design and Approach ...................................................................................52

Research Questions ......................................................................................................53

Role as a Researcher ....................................................................................................54

Setting ..........................................................................................................................55

Study Participants ........................................................................................................59

Sample..........................................................................................................................60

Inclusion and Exclusion Criteria............................................................................60

Participant Selection and Recruitment ...................................................................63

Data Collection Tools ..................................................................................................65

Data Collection ............................................................................................................67

Interviews ...............................................................................................................67

ii
 Focus Groups .........................................................................................................69

Data Analysis ...............................................................................................................71

Ensuring Validity and Reliability in Qualitative Research ..........................................74

Protection of Human Participants ................................................................................76

Summary ......................................................................................................................77

Chapter 4: Presentation of Results .....................................................................................79

Demographic Data .......................................................................................................79

Theme Cluster 1: Characteristics of the Local Government Healthcare System

That Work Well ...........................................................................................................82

Availability ............................................................................................................82

Accessibility...........................................................................................................83

Accommodation and acceptability.........................................................................83

Theme Cluster 2: Challenges and Barriers to the Primary Healthcare System ...........84

Availability ............................................................................................................84

Accommodation .....................................................................................................89

Affordability ..........................................................................................................90

Other Concepts.......................................................................................................91

Theme Cluster 3: Solutions to the Challenges Faced by the Primary Healthcare

System ..........................................................................................................................93

Availability ............................................................................................................93

Accessibility...........................................................................................................95

iii
 Theme Cluster 4: Relationships between Local Health System and Traditional

Healers .........................................................................................................................96

Accessibility...........................................................................................................96

Other Concepts.......................................................................................................97

Theme Cluster 5: Residents’ Confidence in the Healthcare System ...........................99

Availability ............................................................................................................99

Accommodation ...................................................................................................100

Acceptability ........................................................................................................100

Theme Cluster 6: Role of Community-Based Research in Primary Healthcare ........102

Community-Based Research ................................................................................102

Summary of Results ...................................................................................................103

Evidence of Quality ...................................................................................................105

Chapter 5: Discussion, Conclusions, and Recommendations ..........................................108

Summary of Key Findings .........................................................................................109

Interpretation of Findings ..........................................................................................110

Elements of the Primary Healthcare System that Work Well..............................111

(Research Questions 1a and 2a) ...........................................................................111

Barriers to the Successful Implementation of the Primary Healthcare System

(Research Questions 1b and 2b) ..........................................................................116

Solutions to the Challenges Faced by the Primary Healthcare System ...............119

(Research Question 1c and 2c) ............................................................................119

Closer Relationships with Traditional Healers (Research Question 1d) .............121

iv
 Residents’ Confidence Level in the Primary Healthcare System and

Traditional Healing (Research Question 2d) .......................................................124

Potential Role of Community-Based Research in Primary Healthcare ...............128

Applying the Conceptual Framework to the Results .................................................130

Limitations of the Study.............................................................................................133

Implications for Social Change ..................................................................................133

Conclusion .................................................................................................................135

Recommendations for Action ....................................................................................136

Recommendations for Further Research ....................................................................138

References ........................................................................................................................140

Appendix A: Recruitment Flyer—Original Version........................................................166

Appendix B: Recruitment Flyer—Igbo Translation ........................................................167

Appendix C: Recruitment Flyer—Back Translation .......................................................168

Appendix D: Interview Questions for Government Healthcare Administrators .............170

Appendix E: Focus Group Questions for Nurses and Midwives .....................................172

Appendix F: Focus Group Questions for Traditional Healers—Original Version ..........174

Appendix G: Focus Group Questions for Traditional Healers—Igbo Translation ..........176

Appendix H: Focus Group Questions for Traditional Healers—Back Translation .........177

Appendix I: Focus Group Questions for Residents—Original Version ..........................179

Appendix J: Focus Group Questions for Residents—Igbo Translation ..........................181

Appendix K: Focus Group Questions for Residents—Back Translation ........................182

Appendix L: Letter of Introduction—Chairman ..............................................................184

v
Appendix M: Letter of Introduction—Community Leader/Pastor ..................................186

Appendix N: Letter of Introduction—Leader of Traditional Healers ..............................188

Appendix O: Letters of Support From Community Leaders ...........................................190

Appendix P: Data Collection and Analysis Procedures ...................................................192

Appendix Q: National Institutes of Health Certificate ....................................................195

Appendix R: Second-Coder Confidentiality Agreement .................................................196

Appendix S: Consent form for Individual Interviews......................................................198

Appendix T: Consent Form Focus Group—Original Version .........................................202

Appendix U: Consent Form Focus Group—Igbo Translation .........................................206

Appendix V: Consent Form Focus Group—Back Translation ........................................210

Appendix W: Example Coding Notes..............................................................................214

Curriculum Vitae .............................................................................................................219

vi
 List of Tables

Table. Participant Demographics .......................................................................................80

vii
 1

Chapter 1: Introduction to the Study

Many countries have limited access to primary healthcare for residents

(Rutherford et al., 2009; World Health Organization [WHO], 2008b). A combination of

factors contributes to this condition, including sociodemographic characteristics of the

population, lack of resources, challenges posed by the primary-care model, and

government healthcare administrators’ failure to incorporate input from the community

regarding healthcare needs (Higgs, Bayne, & Murphy, 2001; Uneke et al., 2009). As a

result, many people suffer illnesses unnecessarily, and communities experience high

mortality and morbidity rates from preventable causes (Irwin et al., 2006). This

unfortunate situation is the case among many African countries (World Bank, 2011).

Compared to other countries, African countries bear a greater burden of disease

and death from preventable and terminal causes. In fact, 72% of all deaths in Africa are

the result of communicable diseases such as HIV/AIDS, tuberculosis, and malaria;

respiratory infections; and complications of pregnancy and childbirth. Deaths due to these

conditions total 27% for all other WHO regions combined (WHO, 2006). In addition, the

WHO reported that 19 of the 20 countries with highest maternal mortality ratios

worldwide are in Africa. Data from a 2009 report from the World Bank (2011) indicated

that the prevalence of HIV among people ages 15–49 in sub-Saharan Africa is nearly

seven times of that in other areas of the world (5.4% compared to 0.8%, respectively).

Similarly, WHO (2006) reported that Africans account for 60% of global HIV/AIDS

cases, 90% of the 300–500 million clinical cases of malaria that occur each year, and 2.4

million new cases of tuberculosis each year. As of 2003, infant mortality rates were
 2

reported to be 29% higher than in the 1960s (43% up from 14%; WHO, 2006). Lack of

safe drinking water (58% of the population) and access to sanitation systems (36% of the

population) contribute to these poor health outcomes (WHO, 2006). However, these poor

health conditions also are due in part to the historical and current states of primary

healthcare in Africa, and particularly in Nigeria (Asuzu, 2004; National Primary Health

Care Development Agency, 2007; Tulsi Chanrai Foundation, 2007; WHO, 2008b).

Over the years, international attention has been drawn to the global issue of

limited access to primary healthcare for many populations. The outcome of this attention

has been the initiation of numerous efforts to change this condition and develop modern

and effective healthcare systems focused on preventing diseases (McCarthy, 2002;

United Nations Children Fund [UNICEF], 2008; United Nations Population Fund, 2010;

Wang, 2007); reducing disparity in health care (Andaya, 2009; Cueto, 2004; Gofin &

Gofin, 2005; Latridis, 1990; Negin, Roberts, & Lingam, 2010; WHO, 1946); improving

access to healthcare (Bourne, Keck, & Reed, 2006; Dresang, Brebrick, Murray, Shallue,

& Sullivan-Vedder, 2005; WHO Country Office for India [COI], 2008); promoting active

community participation in healthcare planning (International Conference on Primary

Health Care [ICPHC], 1978; International Conference on Primary Health Care and

Health Systems in Africa [ICPHCHSA], 2008; WHO, 1974); and promoting overall

health and well-being (Hall & Taylor, 2003).

Efforts to this end have been effective in many nations (WHO, 2000b, 2008b).

However, the early influence of Christian missionaries (Ityavyar, 1987; Kaseje, 2006),

years of British imperialism leading to the amalgamation of Southern and Northern

 3

Nigeria (Ityavyar, 1987), Nigeria’s continued reliance on the ineffective British system of

healthcare (Ityavyar, 1987), governmental inadequacy (African Development Bank,

2002; Asuzu & Ogundeji, 2007), and a 3-year civil war (Uche, 2008; Uchendu, 2007)

have left the Federal Republic of Nigeria in a state of political, economic, and social

unrest, unable to accommodate a governmental infrastructure to satisfy the diverse

cultural needs of its people (Hargreaves, 2002). Particularly strained is the nation’s ability

to provide access to effective healthcare for its growing population, especially in rural

areas (African Development Bank, 2002). The sociodemographic characteristics of the

population compound this condition (Labiran, Mafe, Onajole, & Lambo, 2008). Access to

healthcare remains inadequate in Nigeria; however, there are very few data on

community perceptions regarding this inadequate access to healthcare in rural Nigeria,

and none in Isu.

Problem Statement

The residents of rural Nigeria lack access to adequate healthcare. One of the many

factors contributing to this lack is the failure of the healthcare system to incorporate input

from the community in planning and implementing services. As a result, there are very

few reports of community input. There is a need to explore community perceptions

regarding access to primary health care in the rural area of Isu. This problem is worthy of

study because inability to access healthcare services is directly related to poor health

outcomes (Cohen, Chavez, & Chehimi, 2007) such as those described in the introduction

to this study.
 4

Purpose of the Study

The purpose of this study was to explore the perceptions of rural community

residents and healthcare providers regarding residents’ access to primary healthcare

services in Isu and to engage in community-based research to demonstrate its potential to

promote resident access to healthcare services. Specifically, I gathered information

regarding availability, accessibility, accommodation, affordability; and acceptability of

government healthcare services; characteristics of the healthcare system that hinder and

that promote residents’ use of healthcare services; and the potential for community-based

research to promote residents’ use of available healthcare services. By exploring these

concepts through study participants’ perspectives, I generated data that may be used in

constructing and distributing a ground-up model of a healthcare system that satisfies the

expressed needs of the people of rural Isu. In addition, I have provided an example of

community-based health access research—a relatively new area of research.

Conceptual Framework

Penchansky and Thomas’s (1981) model of healthcare access provided the

framework that guided this study. According to Penchansky and Thomas, although access

to healthcare is relevant to advancing health legislation and services, the concept has yet

to be adequately defined; however, it is a condition that promotes inequality in healthcare

distribution and widens the gap in health outcomes between the rich and poor,

particularly evident between urban and rural populations. According to Penchansky and

Thomas, access to healthcare does not refer generally to the use of a healthcare system or

the factors that influence that use, nor is it measured by the health of the clients. Rather,
 5

access to healthcare refers to the compatibility between a person and the healthcare

system available to them and is measured by factors that assess patient satisfaction or

prevent them from using healthcare services.

Penchansky and Thomas’s (1981) model of healthcare access provided a

framework for developing my study. Specifically, I considered the five dimensions of

access—availability, accessibility, accommodation, affordability, and acceptability—

while designing Research Questions 1 and 2 so that I could elicit responses related to all

dimensions of access to healthcare in the community. I considered the dimension

accommodation while designing Research Question 3 so that I could elicit responses

related to the community-based research aspect of my study. In addition, I used the five

dimensions of healthcare access to understand the barriers to healthcare access and the

importance of overcoming those barriers as a means of improving rural health conditions.

Also, in my literature review, I organized the presentation of the barriers to healthcare

access according to the five dimensions. The model also provided an organizational

structure for the presentation of my results. Finally, using Penchansky and Thomas’s

(1981) model of access allowed me to present recommendations for improving healthcare

access based on an accepted and proven conceptual framework. By exploring the

conditions of healthcare access for the rural people of Isu through the lens of Penchansky

and Thomas’s model of access, I gathered data that provide a deeper understanding of the

impact of these dimensions of access to the health of Isu residents. Because of this

understanding, I was better suited to present suggestions that may bring about changes in
 6

current government healthcare policies and practices and guide efforts to improve access

to healthcare services for the residents of rural Isu.

Nature of the Study

In this case study, I used qualitative research methods to explore the issue of

healthcare access for the rural people of Isu. To collect data, I used two methods—

personal interviews and focus group discussions—and four data collection instruments.

To analyze the data, I used Colaizzi’s (1973, 1978) seven-step method for coding data

into themes and patterns. To guide my study, I developed three research questions. The

focus of the questions was on the perspectives of healthcare providers and residents

regarding residents’ access to and use of primary healthcare services as well as

community-based research as a means of promoting the use of healthcare services in Isu.

I anticipated that not only would I find differences between the perspectives of

community residents and government healthcare administrators, but also that I would find

differences among healthcare providers themselves. Also, I anticipated that healthcare

administrators would provide insight into administrative or policy issues impacting

primary healthcare. Because nurses and midwives must work with the population of Isu

within the constraints of the government healthcare system, I anticipated that they would

be helpful in providing a broad understanding of the conditions I sought to explore. I

discuss my methodology in more detail in Chapter 3.

Research Questions

To guide this study, I developed three primary research questions and eight

subquestions:
 7

Research Question 1. What are the perceptions of healthcare providers regarding

residents’ access to and use of primary healthcare services provided in rural Isu?

1a. What are healthcare providers’ perceptions regarding the characteristics of the

local government healthcare system that work well?

1b. What are healthcare providers’ perceptions regarding the main challenges and

barriers faced by the local government healthcare system?

1c. What are healthcare providers’ perceptions regarding solutions to the main

challenges faced by the local government healthcare system?

1d. What are healthcare providers’ perceptions regarding the potential for closer

relationships between the local government healthcare system and traditional

healers?

Research Question 2. What are the perceptions of local community members

regarding their access to and use of healthcare services in rural Isu?

2a. What are residents’ perceptions regarding characteristics of the local

government healthcare system that fulfill residents’ needs?

2b. What are residents’ perceptions regarding the main challenges and barriers

faced by the local government healthcare system?

2c. What are residents’ perceptions regarding solutions to the main challenges

faced by the local government healthcare system?

2d. What are residents’ perceptions regarding confidence in the local government

healthcare system and in traditional healers?

 8

Research Question 3. What are the perceptions of healthcare providers and

residents regarding community-based research as a means of promoting the use of

healthcare services among the rural residents of Isu?

Definition of Terms

Access. Based on Penchansky and Thomas’s (1981) model of healthcare access,

refers to a concept that comprises five dimensions: accessibility, availability,

acceptability, affordability, and accommodation, which determine the degree of fit

between clients and a healthcare system.

Community-based participatory research. Focused on a topic relevant to the

community, actively involves community members in the research process, and promotes

positive social change (Centre for Community Based Research, 2011).

Healthcare administrator(s). Person(s) who plan, direct, coordinate, and supervise

the delivery of health care (U.S. Bureau of Labor and Statistics, 2012).

Health system. An organizational framework for the distribution or servicing of

the health care needs of a given community (Asuzu, 2004).

Midwife. An accountable professional who works in partnership with women to

give the necessary support, care and advice during pregnancy, labour and the postpartum

period, to conduct births on the midwife’s own responsibility and to provide care for the

newborn and the infant. This care includes preventative measures, the promotion of

normal birth,
 9

the detection of complications in mother and child, the accessing of medical care or other

appropriate assistance and the carrying out of emergency (International Confederation of

Midwives, 2011).

For the purpose of this study, a midwife is a healthcare provider who may be self-

employed in private practice or may be an employee of the Isu Local Government who is

responsible for administering prenatal, delivery, and postnatal care in government-run

health and community centers or private dedicated locations.

Nurse: A person who cares for the sick or infirm; specifically : a licensed health-

care professional who practices independently or is supervised by a physician, surgeon,

or dentist and who is skilled in promoting and maintaining health (Merriam-Webster

Dictionary). For the purpose of this study, a nurse is a healthcare provider with the

requisite professional nursing license charged with direct care of patients in the in the

local government-run health and community centers. .

Primary healthcare: Healthcare systems include three levels: primary, secondary,

and tertiary. At the primary level, healthcare can be described as a “prevention-oriented

approach to health and well-being” (Cohen et al., 2007, p. 1) and refers to essential health

care based on practical, scientifically sound, and socially acceptable methods and

technology made universally accessible to individuals and families in the community

through their full participation, and at a cost that the community and the country can

afford to maintain (ICPHC, 1978). Primary healthcare is distinguished from secondary

healthcare, which refers to disease intervention and prevention (Cohen et al., 2007);
 10

tertiary health care refers to “reduction of further complications, treatment, and

rehabilitation” associated with disease (Cohen et al., 2007, p. 5).

Residents: All people 18 years and older who live or work in and depend on the

primary healthcare services provided in the Isu Local Government Area.

Traditional healer: A healthcare provider who is not an employee of the Isu Local

Government (private practice), provides healthcare services based on traditional medical

practices (in contrast to medical practices based on Western medicine), and has a

considerable history living among the residents whom he or she serves.

Assumptions and Limitations

The underlying assumption in this study was that by identifying and confirming

healthcare access problems of the people of Isu, ways could be found to improve access

to and use of primary healthcare. I made deliberate choices regarding my chosen topic of

study and study participants. I also acknowledged the limitations associated with these

assumptions.

Regarding the general topic under investigation, I assumed that with regard to

qualitative outcomes, access to healthcare is measurable when it is examined through the

characteristics of accessibility, availability, acceptability, accommodation, and

affordability. This was a limitation because these characteristics may not sufficiently

capture the conditions represented in Isu. However, data from this study may be used to

develop a clearer understanding of these conditions. Also, I assumed that this study

would identify and confirm problems associated with seeking healthcare in Isu and

expose ways to remedy them.

 11

I assumed participants would be honest in their responses, respond willingly, and

participate throughout the duration of the study to the best of their abilities. I also

assumed that participant responses are dependent on participant memory, and how much

they are able to reflect on past conditions or experiences due to the passage of time.

However, when participant responses were analyzed for themes, the data provided

general patterns of perspectives that may be useful in designing a model of healthcare

delivery that meets the needs of the people of rural Isu.

I assumed that the results of this study would accurately reflect conditions in Isu

of residents’ access to healthcare services and provide data useful for developing a model

of health care based on the specific needs described by residents of rural Isu. In addition,

I assumed that these data would be relevant to healthcare providers in that area. These

assumptions were limitations because I used a small sample of the population from which

to gather my data. Thus, the sample may not have represented the overall experiences of

the total population, and my ability to generalize findings to the entire population of Isu,

and especially to other local communities, was limited. However, this study serves as an

initial attempt to understand conditions related to residents’ access to healthcare services

in Isu and provides a valuable foundation for the development of a model of healthcare

delivery that meets the needs of the people of rural Isu and for additional study on this

topic.

Scope and Delimitations

The scope of this study comprised residents’ and healthcare providers’

perceptions of resident access to healthcare services in rural Isu, as well as the potential
 12

of community-based research to improve resident use of healthcare services. This study

was delimited to four specific groups: government healthcare administrators, nurses and

midwives, traditional healers, and residents of Isu. Government healthcare administrators

included in this study held senior administrative or leadership positions in the health

department or positions directly involved in healthcare decision making at the local

government and had worked in that capacity for at least 3 years. Nurses were actively

working in government-supported healthcare facilities, and midwives were actively

working either in government-supported healthcare facilities or in private practice. All

nurses and midwives were licensed to practice and had no less than 3 years’ experience

providing direct healthcare services. Traditional healers were residents of Isu and had

provided healthcare services to the local population for at least 5 years. Residents had

lived in Isu for at least 5 years and could not have been employed as government

healthcare administrators, nurses or midwives, or traditional healers. All participants

were over the age of 18 and capable of giving informed consent and participating fully in

all aspects of the study. No potential participants were excluded based on race or gender.

Significance of the Study

The literature demonstrated that health research in general contributes to

improved decision-making procedures for healthcare administrators and performance of

national healthcare systems (Briss, Gostin, & Gottfried, 2005). Specifically, community-

based research supports positive social change (Centre for Community Based Research,

2011). Results from this study add to the body of knowledge that community-based
 13

research can generate important information to support social change, such as the

improvement of people’s access to healthcare.

By exploring the conditions affecting access to healthcare in Isu, I generated data

that the Isu Local Government Area chair and healthcare administrators can use to

construct and distribute a ground-up model of healthcare that satisfies the expressed

needs of the people of rural Isu. In addition, private-practice healthcare providers could

implement aspects of the model appropriate for improving patient care in private-practice

situations. Ultimately, such efforts by healthcare providers may offer a means of

improving resident access to healthcare in Isu and contribute to the reduction of

healthcare inequity among residents.

Summary and Content of the Remaining Chapters

Limited access to healthcare services can be a major cause of health disparity in

any population (Bourke, 2006; Irwin et al., 2006). Thus, increasing access to primary

healthcare is critical to decreasing rates of death and sickness from preventable causes.

Primary healthcare is designed to promote good health by reducing mortality and

morbidity (Irwin et al., 2006), support overall health and well-being, and improve

community and individual behavior regarding self-management of healthcare—all of

which can result in tremendous savings in financial and human resource investments in

secondary and tertiary levels of healthcare (World Bank, 1993; WHO, 2000c). For

example, Kaseje (2006) indicated that poor access to healthcare results in a lack of access

to modern health facilities for 50% of the African population, and consequently, low

levels of immunization and high levels of maternal, child, and infant mortality.
 14

According to Kaseje, for primary health care to meet the needs of contemporary society,

it has to adopt a business attitude of tailoring services to needs; it is essential that

healthcare administrators seek input from community members and incorporate this input

in healthcare plans and programs. Community-based research provides that opportunity

for implementing a community-oriented healthcare delivery system.

Penchansky and Thomas’s (1981) theory of access provided a guide for

understanding the different factors that inhibit or promote healthcare access for

consumers and improve healthcare use. Healthcare access largely is determined by

availability, accessibility, accommodation, affordability, and acceptability (Penchansky

& Thomas, 1981). Because no research has been done in this community, in this regard,

gathering primary data through personal interviews and focus-group discussion was an

appropriate step for bringing a community together to talk about their problems and

suggest solutions. This method produced real-life experiences from people living the

phenomenon under study, which were relevant for identifying obstacles to healthcare

access and which will be relevant for improving healthcare use and creating a need for

continued use of community input to solve community health problems. I analyzed the

collected data using Colaizzi’s (1973, 1978) seven-step method for content analysis.

In Chapter 2, I review literature on the traditional healthcare system and modern

efforts to improve primary healthcare, including health reforms in Nigeria from colonial

times to the present. In Chapter 3, I discuss the study’s methodology, including the study

design and approach, research questions, data-collection methods and instruments, and

procedures for data analysis. In Chapter 4, I present my findings. In Chapter 5, I provide

 15

an interpretation of the findings, discussing the findings as they relate to the theoretical

framework used in this study; and offer study limitations, recommendations for action,

recommendations for future study, and implications for social change.

 16

Chapter 2: Literature Review

Most residents of rural Nigerian communities suffer from lack of access to

healthcare, which results in death and sickness from preventable causes. One of the many

factors contributing to this situation is the failure of the healthcare system to incorporate

input from the community in planning and implementing services. The intent of this

study was to explore the perceptions of rural community residents and healthcare

administrators and providers regarding residents’ access to primary healthcare services in

Isu, and to engage in community-based research to demonstrate its potential to promote

resident access to healthcare services. This section comprises six major subsections. First,

I provide a detailed discussion of the conceptual framework I used in this study. Second,

I present a historical and modern overview of the Nigerian healthcare system. Third, I

present literature related to healthcare conditions in Nigeria to illustrate the healthcare

crisis in Nigeria and illuminate the importance of this study. Fourth, I discuss the

importance of primary healthcare to a population’s health. Fifth, I present literature

related to barriers to healthcare access and the role of community-based research in

improving healthcare. Last, I discuss literature relating to the methodology of this study.

As part of my exploration into perceptions of healthcare access in Isu, I conducted

a review of applicable literature. I searched scholarly literature databases via Academic

Search Complete, Health Science Research, Science Direct including the Education

Resources Information Center (ERIC), and gathered information from scholarly journal

articles, magazine articles, reports, fact sheets from state and private organizations, and

books. I selected literature based primarily on publication dates between 2000 and 2011.
 17

When I included literature published before 2000, I did so because it either represented a

significant contribution to the field of study or because it contributed to the well-rounded

description of the conditions prompting this study. Search terms included primary

healthcare, healthcare, access to healthcare, traditional healing in Nigeria, health

disparity,, barriers to primary healthcare, achievements of primary healthcare,

community-based research, rural health, Nigerian National Health Insurance Scheme,

Nigerian Development Plan, colonial health model, problems of healthcare in Africa, and

healthcare perceptions.

Conceptual Framework: A Model of Healthcare Access

According to Penchansky and Thomas (1981), access to healthcare refers to the

compatibility between a person and the healthcare system available to him or her and is

measured by factors that assess patient satisfaction or prevent them from using the

healthcare services. To define access and provide a means by which to measure it,

Penchansky and Thomas conducted a quantitative study using survey data collected in

Rochester, New York in 1974 from General Motors Corporation electrical-parts

assembly-plant personnel and their spouses. Penchansky and Thomas’s primary purpose

was to explore what factors contributed to participants’ choice of a healthcare plan and

what roll satisfaction played in those choices. The researchers used one questionnaire for

employees and another for spouses, and although 626 employees and spouses originally

participated in the study, only 287 people completed all the survey questions pertaining to

satisfaction. The researchers scored participant responses using a 5-point Likert scale and

found that 16 items related to five dimensions of access. As a result of this work,
 18

Penchansky and Thomas outlined five closely related dimensions of healthcare access:

availability, accessibility, accommodation, affordability, and acceptability (p. 127).

Availability refers to the relationship between the supply and demand of available

health services (Penchansky & Thomas, 1981). In this dimension, Penchansky and

Thomas suggested there is a relationship between the number of healthcare facilities,

healthcare personnel (physicians and paraprofessionals), and types of services offered

and the extent and types of need expressed by a population. As described by Cham,

Sundby, and Vangen (2005), availability measures the extent to which available services

meet the health needs of the population being served.

Accessibility refers to the degree of fit between clients and the healthcare system

(Penchansky & Thomas, 1981). According to Penchansky and Thomas (1981), the focus

of this dimension is “the relationship between the location of supply and the location of

clients, taking account of client transportation resources and travel time, distance and

cost” (p. 128). McLaughlin and Wyszewianski (2002) described this dimension as

geographic accessibility, “determined by how easily the client can physically reach the

provider’s location” (p. 1441). Clark (1983) and Ige and Nwachukwu (2010) described

accessibility as equity in healthcare. Similarly, according to WHO (2000b), a healthcare

service, regardless of its proximity to a client, cannot be said to be accessible if a client is

unable to pay for the service.

Accommodation refers to the relationship among the manner in which the supply

resources are organized to accept clients (including appointment systems, hours of

operation, walk-in facilities, and telephone services), the clients’ ability to accommodate
 19

to these factors, and the clients’ perception of their appropriateness (Penchansky &

Thomas, 1981, p. 128). In this dimension, Penchansky and Thomas suggested that even

when all other factors are adequately provided, people still will not seek or continue to

use a healthcare system in which the design and operation do not consider their

sociocultural circumstances.

Affordability refers to the “relationship of price of service and providers’

insurance or deposit requirements to the clients’ income, ability to pay, and existing

health insurance” (Penchansky & Thomas, 1981, p. 128). According to the World Bank

(1993), affordability also is related to increases in healthcare costs and associated

outcomes for patients.

Acceptability refers to “the relationship of clients’ attitudes about personal and

practice characteristics of providers to the actual characteristics of existing providers, as

well as provider attitudes about acceptable personal characteristics of clients” (p. 129). In

this dimension, Penchansky and Thomas suggested clients may determine provider

acceptability based on demographic characteristics and location of a facility, whereas

providers may develop attitudes toward clients based on sociodemographic

characteristics and need for physical accommodations (p. 129).

Because Penchansky and Thomas (1981) developed the five dimensions of access

model, researchers have used it as the basis for measuring the impact of access to

healthcare on health outcomes. More recently, Bourke (2006) used it to explore

consumers’ perspectives regarding access to healthcare, and Rutherford, Mulholland, and

Hill (2010) used it to explore the impact of healthcare access on child mortality. I discuss
 20

the details of these studies more thoroughly later in this chapter in the barriers to

healthcare access section.

Traditional Healthcare System in Nigeria

Health and religious beliefs are tightly interrelated and thus have influenced how

Nigerians have perceived health and healing from the earliest time of traditional medicine

to the introduction of Western medicine in the late 1800s (Awojoodu & Baran, 2009;

Ityavyar, 1987). The health perspectives of many Nigerians continue to be influenced by

religious beliefs (Abubakar, Musa, Ahmed, & Hussani, 2007; Okeke, Okafor, &

Uzochukwu, 2006). Because of the strong religious connection with health, the people of

Nigeria have long believed certain illnesses to be associated with wrongdoings in the past

or present world and their offense of gods and evil spirits (Nwoko, 2009; Onyioha, 1987).

For example, the Hausas and Fulanis of northern Nigeria believe that cancer is caused by

contact with an evil spirit (Abubakar et al., 2007). Among the Igbos, convulsions

associated with malaria are believed to be diabolic (Okeke et al., 2006). Similarly, the

Igbos believe mental illness to be the work of evil spirits (Nwoko, 2009). For this reason,

historically, healthcare systems in Nigeria have been based on traditional medical

practices and administered by traditional medical practitioners (healers) and birth

attendants (Nwoko, 2009).

These traditional healers often are priests or religious people with a good

knowledge of herbs and spiritual appeasements who are called on to diagnose and cure

illness (Awojoodu & Baran, 2009). To be successful, healers must understand the

physical, mental, spiritual, and social environment of the patients they treat (Onyioha,
 21

1987). This practice regularly includes mending the relationship between patients and

their chi (creator) or the spirits of the ancestors (Izugbara & Duru, 2006; Offiong, 1999).

Often, traditional healers are called on to prepare healing concoctions, typically

consisting of plants, herbs, and animal products (Okeke et al., 2006). In some cases, the

healers perform healing ceremonies, including the use of healing concoctions and often

animal sacrifices (Mafimisebi & Oguntade, 2010). Birth attendants perform deliveries,

care for the health needs of pregnant and nursing mothers, and perform circumcisions;

they also treat patients for infertility and manage threats of miscarriage (Ofili & Okojie,

2005). Although not adherent to strict spiritual practices associated with traditional

healing medicine, birth attendants regularly use herbs when performing deliveries and

providing pre- and postnatal care (Peltzer, Phaswana-Mafuya, & Treger, 2009).

Traditional medical practices have been fundamental to healthcare delivery in

Nigeria because they help maintain patient–healer relationships and thus support open

communication between patients and healers. Traditional healers live among the people,

providing services that are accessible, affordable, and culturally acceptable to the people

(Abioye-Kuteyi, Elias, Familusi, Fakunle, & Akinfolayan, 2001; Saad, Azaizeh, & Said,

2005). In addition, healers display a pragmatic approach in obtaining personal health

information and histories from their patients—they use clues and language common to

the people (Onyioha, 1987). When necessary, they also obtain information by observing

and analyzing the patients’ sociocultural environment, which may suggest the need to

repair relationships between the patients and offended spirits (Ityavyar, 1987).
 22

This pragmatic approach to particular aspects of patient information and service

typically is missing from consultations between patients and Western medical

practitioners (Abubakar et al., 2007). In fact, the persistent use of traditional healers and

birth assistants today rests on the healers’ and birth assistants’ ability to understand their

patients and their patients’ belief systems (Saad et al., 2005), adapt their services to the

needs of their patients (Offiong, 1999), and provide services based on sincere interest in

patient health rather than interest in making profit (Titaley, Hunter, Dibley, & Heywood,

2010). These conditions fit well with the typical health-seeking behaviors of the people of

Nigeria.

Modern Healthcare Systems

International Origins and Scope of Primary Health Care

Over the years, international attention has been drawn to the global issue of poor

access to primary health care (ICPHC, 1978). The outcome of this attention has been the

initiation of numerous efforts to change this condition and develop modern and effective

healthcare systems focused on preventing diseases, reducing disparity in health care,

improving access to healthcare, promoting active community participation in healthcare

planning, and promoting overall health and well-being.

Beginning in the 1940s, individual health professionals and health organizations

in Africa and around the world began engaging in projects and programs that defined

primary health care and worked to improve access for those without it. For example, in

the 1940s in rural South Africa, Sidney and Emily Kark began to promote the concept of

primary health care, or community-based primary care, a comprehensive approach to care

 23

that took into account the “socioeconomic and cultural determinants of health, identifying

health needs, and providing health care to the total community” (Gofin & Gofin, 2005, p.

1). The focus of this type of care was community participation, preventive care, and

provision of services that are affordable and accessible to the people in need (Gofin &

Gofin, 2005).

Less than a decade later, in 1946, the Indian government set up the Bhore

Committee to study and recommend ways of improving public access to healthcare

(WHO COI, 2008). Among their recommendations were “(a) integration of preventive

and curative services at all administrative levels, (b) short term-primary health centers for

40,000, (c) formation of village health committee, [and] (d) three months’ training in

preventive and social medicine to prepare social physicians” (WHO COI, 2008, p. 1).

This innovative approach to public health access led the way for the formation of WHO

in 1946.

WHO (1947) was established by the United Nations to deal with global issues of

health among member nations. WHO promoted the idea that good health is a fundamental

human right and that populations and states alike would benefit from state involvement in

the promotion of good health (WHO, 1946). In its constitution, WHO identified health

not as the absence of disease but more holistically “as a state of complete physical,

mental, and social wellbeing” (p. 1). Since its inception, the organization has provided

guidelines, formulated health policies, encouraged intra-agency collaborations, and

presented declarations as a means of urging member nations and healthcare providers to

adopt healthcare policies and programs that are relevant to established needs, and to
 24

improve global access to healthcare as a means of improving healthcare and healthcare

outcomes (WHO, 2008b). During the same year, the United Nations created what is now

the United Nations Children’s Fund (UNICEF, 2011) “to provide food, clothing and

health care” (para. 1) to European children facing famine after World War II.

During the 1960s and 1970s, the People’s Republic of China experienced a

growing demand for the expansion of rural medical services (Cueto, 2004). This demand

led to the development of the barefoot-doctor program: a program that trained local

farmers in basic and paramedical procedures as a means of servicing members of rural

communities not otherwise able to gain access to trained physicians (Cueto, 2004). The

barefoot-doctor program was primarily concerned with preventive rather than curative

measures and focused on serious disease planning, mutual aid, and fraternity between

rural residents in the healthcare system (Wang, 2007).

Like the barefoot-doctor program in China, Cuba implemented a community-

based program to improve primary healthcare delivery to the most remote and vulnerable

populations of its society (Bourne et al., 2006). In 1964, Cuba began to develop a

community-based healthcare system that “focused on wellness rather illness;

incorporated social, political, and psychological aspects of wellness into medical practice

with the help of community support-groups; and developed a unified service-delivery

system” (Latridis, 1990, p. 30). The underlying framework for this system was a network

of doctors who lived among the people they cared for, which allowed for uninterrupted

access to healthcare, but also the opportunity for doctors to develop intimate relationships

with their patients (Andaya, 2009). Similarly, in Fuji during the 1970s, doctors and
 25

nurses “had been delivering health services on horsebacks to villages, built dispensaries,

and trained local residents on the treatment of minor ailments” (Negin et al., 2010, p. 14).

The attainment of independence during the 1960s and 1970s by otherwise

colonized countries also stimulated the desire to provide health services to improve the

life and welfare of the people through the provision of high-standard healthcare,

education, and other services (Hall & Taylor, 2003). In Tanzania, for example, the

government began a primary healthcare program through a network of multisectoral

primary healthcare committees at national, regional, district, ward, and village levels

(Primary Health Care Institute, 2010).

The appointment of a new director general for WHO in 1973 resulted in a new

understanding of the roles of WHO and UNICEF in the provision of basic health care

(Cueto, 2004). That understanding led WHO and UNICEF to produce a collaborative

report, Alternative Approaches to Meeting Basic Health Needs in Developing Countries,

identifying key factors in health care for a variety of countries, including Bangladesh,

China, Cuba, India, Niger, Nigeria, Tanzania, Venezuela, and Yugoslavia (Cueto, 2004).

The report suggested that, for such developing countries, “the principal causes of

morbidity … are malnutrition, vector- borne diseases, gastrointestinal diseases, and

respiratory diseases—themselves the result of poverty, squalor and ignorance”

(Djukanovic & Mach, 1975, p. 14).

In 1974, the World Health Organization established the Expanded Program on

Immunization (EPI) to address root causes of death and disease among children and

vulnerable populations in the world (Centers for Disease Control and Prevention, 2011).
 26

Specifically, EPI focused on the prevention of death from the five known prominent

diseases at that time: diphtheria, whooping cough, tetanus, measles, poliomyelitis, and

tuberculosis (United Nations Population Fund, 2010). Although EPI targeted residents in

poor environments and those with restricted access to healthcare, EPI struggled to reach

residents with logistic problems, low capacity of health workers, and lack of availability

of vaccines (Salaudeen, Musa, & Bello, 2011).

Health education as an essential tool for improving community health through

self-empowerment became evident with the introduction of the Twenty-Seventh World

Health Assembly Resolution. The resolution emphasized health education as a means to

“improve health care utilization, increase community participation, and involve people in

new responsibilities for their own health, that of others, and for the global community”

(WHO, 1974, p. 3). The Twenty-Seventh World Health Assembly Resolution added that

the most critical element for improving the health of the population was an informed

public that could cooperate actively in their own healthcare (WHO, 1974, p. 5). This

concept highlighted the importance of community partnership and participation in

effective planning and implementation of healthcare.

One of the most notable efforts to advance improved public access to healthcare

was the Declaration of Alma-Ata, an outcome of the 1978 International Conference on

Primary Health Care joint conference sponsored by WHO and UNICEF (Cueto, 2004).

The purpose of the conference was to focus attention on primary healthcare as a way of

promoting global health and removing injustice in the distribution of health outcomes

(Cueto, 2004). In the Declaration of Alma-Ata, members of the conference defined

 27

primary healthcare as essential health care based on practical, scientifically sound, and

socially acceptable methods and technology, made universally accessible to individuals

and families in the community through their full participation, and at a cost that the

community and the country can afford to maintain at every stage of development in the

spirit of self-reliance and self-determination (ICPHC, 1978, p. 1).

Synthesizing primary healthcare concepts from various countries, members of the

conference indicated that healthcare should (a) consider the economic, sociocultural, and

political conditions of the population it is intended to serve; (b) focus on promotion and

prevention in addition to curing and rehabilitating; (c) promote education; (d) appeal to

all sectors of the population; (e) use local and national resources to promote a

population’s involvement in healthcare planning and implementation; (f) be sustainable

and progressive; and (g) rely on appropriately trained healthcare workers as well as

traditional practitioners (ICPHC, 1978; Negin et al., 2010).

Taking note of the continued limited access to healthcare resulting in low

investment in healthcare-sector infrastructure and human development and inequality in

income in sub-Saharan Africa, WHO and UNICEF again joined forces in 1987 to sponsor

the Bamako Initiative (Ridde, 2011). This initiative was designed to be a pragmatic

strategy to source funding for healthcare and focused on (a) reversing dwindling national

expenditures for healthcare, (b) increasing access to primary healthcare, (c) promoting

equity in health services, (d) improving communication between healthcare providers and

communities, and (e) ensuring a regular supply of essential drugs at affordable costs

(Ridde, 2011; UNICEF, 1999; World Bank, 2004a). Worldwide outcomes from the
 28

Bamako Initiative were significant, including the revitalizing of a number of health

centers and community health centers, which improved and sustained immunization

coverage and increased the capacity to provide essential drugs and services to otherwise

unreachable local communities (Ridde, 2011).

In 2008, the international and regional agency members of ICPHCHSA (2008)

united to reaffirm and update the objectives of the 1978 Declaration of Alma-Ata. After

reviewing past experiences in primary healthcare, the members drafted the Ouagadougou

Declaration, in which they defined strategies for attaining what they called millennial

development goals. In addition, members called on African countries to expedite the

restructuring of their healthcare systems to better meet the primary healthcare needs of

their people (Nyonator, Awoonor-Williams, Phillips, Jones, & Miller, 2002). The

conference emphasized that a primary healthcare program must aim to prevent and cure

diseases and to promote health and health education in the communities in which they

intend to serve by focusing on nine priority areas: leadership and governance, health

service delivery, human-resource development, health financing, health information,

community participation and ownership, health research, health technologies, and

partnership for development (ICPHCHSA, 2008).

According to WHO (2003), global action initiated in the last 7 decades

demonstrated progress. For example, WHO (2003) indicated (a) a global increase in life

expectancy, total adult literacy, and reduction in infant and under-5 mortality;

(b) increased initiatives and efforts to promote primary healthcare delivery to vulnerable

populations; (c) democratization of health programs through community-building

 29

initiatives; (d) improved human-resource development in healthcare delivery, especially

in the training of health workers such as traditional birth attendants and community

health workers; and (e) stimulated national interest in grassroots healthcare delivery and

the recognition of healthcare as a basic human right (pp. 2–6).

Postcolonial Development in Nigeria

Since gaining its independence from the British in 1960, Nigeria, like other

nations, has engaged in notable attempts to reform healthcare for its people (Ityavyar,

1987). For example, the First National Development Plan—a series of small projects—

was initiated between 1962 and 1968 as an initial attempt to restructure the nation’s

government and healthcare system under the new Federal Republic of Nigeria (Scott-

Emuakpor, 2010). With minimal change initiated as the result of these projects, between

1970 and 1974, Nigeria developed and implemented the Second National Development

Plan—also called the Post-Independence Health Plan (Asuzu, 2004).

The Second National Development Plan focused on the use of national planning

to implement social change in the face of the destruction brought on by civil war

(Erundare, 1971). The plan focused on developing “a united, strong and self-reliant

nation; a great and dynamic economy; a just and egalitarian society; a land of bright and

full opportunities for all citizens; and a free and democratic society” (Federal Republic of

Nigeria, as cited in Erundare, 1971, p. 151). Shortly after, when efforts based on the

Second National Development Plan failed to effect the expected changes, Nigeria

developed the Third National Development Plan for the years 1975–1980 (Attah, 1976;

Scott-Emuakpor, 2010). The purpose of this plan, among other things, was to emphasize
 30

primary healthcare through the development of the Basic Health Service Scheme (BHSS;

WHO, 2008a). Recognizing the value of traditional birth attendants as a means of

reducing reproduction-related deaths, in 1979, the Third National Development Plan

incorporated traditional birth attendants into the healthcare system (Ofili & Okojie,

2005). According to Scott-Emuakpor (2010), the Third National Development Plan

“focused [more] attention on trying to improve the numerical strength of existing

facilities rather than evolving a clear health care policy” (p. 55).

After the Third National Development Plan failed to effect significant change,

Nigeria developed the Fourth National Development Plan for the years 1981–1985

(Scott-Emuakpor, 2010). The purpose of this plan was to address the inherent problems

posed by the previous national development plans and focused on the BHSS as a means

of implementing preventive care (Scott-Emuakpor, 2010). The implemented structure

allocated federal and state funds for local-government operation of facilities at three

levels depending on population size: comprehensive health centers for populations of

more than 20,000, primary health centers for populations of 5000–20,000, and health

centers for populations of 2000–5000 (Scott-Emuakpor, 2010, p. 55).

When the Fourth National Development Plan failed to foster meaningful

improvement, Nigeria developed the Fifth National Development Plan for the years

1987–1991 (Scott-Emuakpor, 2010). During the time of this plan, in 1988, Nigeria

adopted the philosophy of the Bamako Initiative “to strengthen primary care and promote

healthcare at the community and local government levels” (Ogunbekun, Adeyi, Wouters,
 31

& Morrow, 1996, p. 369), which helped ensure access to affordable and sustainable

primary healthcare services through the revitalization of health centers (Bellamy, 1999).

Prompted by the Fifth National Development Plan and Nigeria’s new philosophy

of healthcare, Nigeria developed the first National Health Plan, which led to explicit

formulation and adoption of a national primary healthcare policy in 1988 (Federal

Ministry of Health, 2004). One of the significant outcomes of the newly implemented

healthcare policy was a national 3-year rolling plan focused on promoting immunization,

family-planning care (Osibogun, 2004), and child healthcare (Federal Ministry of Health,

2004). The Revised National Health Plan of 2004 called for a “comprehensive healthcare

system, based on primary healthcare that is promotive, preventive, restorative and

rehabilitative to every citizen of the country, within the available resources, so that

individuals and communities are assured of productivity, social well-being and

enjoyment of living” (Federal Ministry of Health, 2004, p. 7).

In 1999, the Nigerian federal government implemented the National Health

Insurance Scheme (NHIS) to provide easy access to health care for all Nigerians at an

affordable cost through various prepayment systems (NHIS, 2005). The NHIS “is

designed to facilitate fair financing of healthcare costs through pooling and judicious

utilization of financial risk protection and cost-burden sharing for people, against the high

cost of healthcare through institution of prepaid mechanism, prior to their falling ill”

(NHIS, 2005, para. 3). Since its inception, the NHIS has accredited and registered almost

6,000 providers and numerous other financial institutions (NHIS, 2005).

 32

As the United Nations Population Fund (2010) noted, Nigeria’s recognition of its

“weak health systems and its consequence on access and utilization of services and

ultimately serving as one of the precursors to high mortality morbidity rates led to the

commencement of national efforts” (para. 3) to address the system’s weaknesses. For

instance, in 2006, the Federal Ministry of Health (FMOH) introduced the Midwives

Service Scheme (MSS) to reduce the high rates of child and maternal mortality in the

country. The strategy of the MSS was founded on the principal of making skilled birth

attendants accessible to the people by deploying newly qualified, unemployed, or retired

midwives to local communities (FMOH, 2006). The implementation of the MSS was an

indication that the FMOH recognized the “state of maternal, newborn and child health is

an important indicator of [a nation’s] healthcare delivery system and the level of the

society’s development” (FMOH, 2009, p. 3).

Also, Nigeria sponsored the Nigerian Health Conference to review specific issues

affecting Nigeria (Uzodinma, 2012). Uzodinma (2012) summarized the identified

objectives of the conference: to provide a means for Nigerian stakeholders in the health

sector to interact with a focus on primary health care, to develop strategies to ensure that

Nigerian primary health care resembles that depicted by the Declaration of Alma-Ata,

and to examine the Ouagadougou Declaration’s Millennium Development Goals 4, 5, and

6 in light of Nigeria’s healthcare-system performance.

As the result of isolated programs developed and promoted by the various

National Development Plans and the most recent National Health Plan, certain clinical

indices in Nigeria have shown improvement. For example, Nigeria has reached
 33

elimination levels of leprosy, with less than one identified case per 10,000 people since

1998, and between 1988 and 2007, guinea worm disease has declined from 653,000 cases

to 73, (WHO Country Office for Africa [COA], 2007). In addition, the implementation of

polio vaccines in 2006 led to an 80% drop in occurrence the following year (WHO COA,

2007). However, the prevalence of HIV/AIDS in Nigeria continues to be high, with 2.86

million people infected in 2005 (WHO COA, 2007), and despite global efforts to improve

access to primary healthcare and the success of these efforts throughout the world,

primary healthcare systems in Nigeria remain ineffective.

Healthcare Conditions in Nigeria

Access to healthcare in Nigeria is extremely limited. This condition is the result of

a variety factors, including the early influence of Christian missionaries, Nigeria’s

continued reliance on the ineffective British system of healthcare, and insufficient

resources and skills in the area of health administration (Asuzu & Ogundeji, 2007;

Ityavyar, 1987; Kaseje, 2006).

The Catholic Church built its first hospital in Africa in 1504, and the Church

Missionary Society sent the first Western physicians to Nigeria in 1850 (Ityavyar, 1987).

Although the missionaries established hospitals, dispensaries, and leprosy clinics; were

responsible for educating nurses, midwives, and other paramedical personnel; and staffed

facilities with physicians, the ultimate purpose of their presence was evangelical in nature

(Ityavyar, 1987). In addition, health facilities were located in major urban areas where the

missionaries were stationed. Further, the facilities did not follow any known national

healthcare plan but rather were designed on an individual basis to suit the particular
 34

interests of the missionaries who built them (Osibogun, 2004). The British refined this

system with efforts to eliminate traditional medical practices, placing emphasis on

curative rather than preventive medicine and on the establishment of health facilities in

urban areas (Ityavyar, 1987).

Although the influence of Christian missionaries, Western medicine (Kaseje,

2006), and the British system of healthcare have contributed to the lack of access to

primary healthcare in Nigeria, the inadequacy of the organizational and structural nature

of the nation’s government also has contributed to this condition. For example, both the

Second and Third National Development Plans failed to clearly identify government

responsibilities in healthcare planning and implementation related to specific areas such

as resource generation, staffing development, health-professional deployment, and

service delivery (WHO, 2008a). In addition, the African Development Bank (2002)

reported the government was poorly developed, had little interest in investing in

healthcare, was able to support few universities to train health professionals, and suffered

from poor human-development capacity. Further, the government generally suffered from

limited finances and lack of personnel to implement the programs and support its

objectives, including those outlined in the BHSS (Asuzu & Ogundeji, 2007).

Uzodinma (2012) summarized the concerns identified at the Nigerian National

Health Conference. These concerns included not only the poor outcomes associated with

lack of access to healthcare but the underlying causes of the poor healthcare system as

well, such as lack of adequate progress toward improved conditions; “lack of

coordination; fragmentation of services; dearth of resources, including drug and supplies;

 35

inadequate and decaying infrastructure; inequity in resource distribution and access to

care, and very deplorable quality of care” (Uzodinma, 2012, para. 4, item 3).

Uzodinma (2012) also noted a general lack of funding as well as Nigeria’s use of

Millennium Development Goal funding to replace rather than supplement government

funding. In addition, Nigeria faces human-resource challenges such as a poor work ethic

among healthcare providers and lack of adequate supervision for healthcare providers, as

well as an overburdened government with little interest in responsibility for primary

healthcare (Uzodinma, 2012). Also, although some healthcare policy has been

implemented at the national level, leadership and governance to implement them at the

local levels remains poor; attempts to manage policy in isolation from social determinants

of individual health and without credible data and evidence-based planning remains a

barrier to progress (Uzodinma, 2012).

Finally, poor program acceptance and support has reduced access and use of

primary healthcare in Nigeria. That few Nigerian states have enrolled in the NHIS (2005)

exemplifies this poor program acceptance. That the MSS has been met with various

challenges (including shortage of midwives, poor retention of midwives, high withdrawal

rates, and state and local governments’ inability to contribute their expected share to the

scheme) exemplifies poor levels of support (Abdullahi, 2010).

Fairchild, Rosner, Colgrove, Bayer, and Fried (2010) suggested that to improve

health outcomes, the current healthcare system needs to shift its focus from its previous

concern with environmental sources of infection to a concern with the individual (p. 54).

This shift requires that governments implement, as part of their national health system or
 36

policy, a program that eliminates deficiencies in living conditions that are precursors to

diseases and poor health (Fairchild et al., 2010). Although continued revisions to the

National Health Development Plan indicate Nigeria’s recognition of the importance of

primary healthcare and intent to commit to addressing such deficiencies and improving

primary healthcare access for its populations, inequity in healthcare remains a problem in

Nigeria (Uzodinma, 2012). Rural communities continue to be affected most by the

government’s failure to envision that effective healthcare delivery begins with making it

available and accessible to the most vulnerable populations (Ajayi, 2009). Incorporating

community-based research on health-seeking behaviors into healthcare policymaking and

healthcare programs may offer an avenue for improving community access to healthcare

(Uneke et al., 2009).

The Importance of Primary Healthcare

According to WHO (2008b), current health services are inadequate: “People are

increasingly impatient with the inability of health services to deliver levels of national

coverage that meet stated demands and changing needs, and with their failure to provide

services in ways that correspond to their expectations” (p. xi). WHO (2008b) suggested

that primary healthcare is a means of meeting the healthcare needs of populations

worldwide, but that nations have failed to develop it quickly enough and well enough to

keep up with conditions in a highly dynamic global setting. Studies have indicated the

potential for primary healthcare to positively impact health outcomes.

 37

For example, Starfield, Shi, and Macinko (2005) conducted a review of literature

focusing on the importance of primary healthcare in health outcomes. The authors

identified six benefits that derived from effective primary healthcare systems:

greater access to needed services, better quality of care, a greater focus on

prevention, early management of health problems, the cumulative effect of the

main primary care delivery characteristics, and the role of primary care in

reducing unnecessary and potentially harmful specialist care. (p. 474)

The researchers found that despite high per capita income on healthcare in the United

States, the nation still is not successful with major health indicators—they suggested that

primary healthcare is the best option to achieve better healthcare at a cost that is

accessible to the nation’s people (Starfield et al., 2005).

Atun (2004) conducted a similar review of studies. In Atun’s study, the researcher

sought to determine, among other things, “the relationship between access to primary

care and health outcomes, patient satisfaction and cost” (p. 6). The author reviewed

various key journals for literature on studies that used systematic reviews, randomized

control trials, quasiexperiments, evaluative studies, and case-control studies. Atun found

that efficient healthcare systems produce better population health outcomes contrary to

increased mortality and morbidity from a poorly managed or organized healthcare

system.

Magnussen, Ehiri, and Jolly (2004) sought to compare comprehensive primary

healthcare to selective healthcare as they impact global health. The authors agreed that

only a primary-care system would “respond more equitably, appropriately, and

 38

effectively to basic health needs and also address the underlying social, economic, and

political causes of poor health” (p. 168). Primary healthcare has been identified as a

significant tool for reducing risks associated with chronic and lifestyle factors and for

improving performance in preventive care (Harris, 2008). Harris (2008) explained that

primary healthcare will be useful in early detection, assessing and managing chronic

disease conditions, and enabling people to take personal control.

Bourke (2006) framed questions around access to health care to understand the

perspectives of consumers about their access to healthcare. Bourke found that access to

healthcare is a major factor in health outcomes and that poor health status is associated

with less or limited access to health services. In addition, Bourke found that

understanding consumer perspectives is critical to improving health services, especially

for rural populations. Rutherford et al. (2010) used Penchansky and Thomas’ (1981)

model as a framework to conduct a systematic review of the impact of access on

mortality for children under 5 years of age in sub-Saharan Africa. The authors proposed

that access is multidimensional and involves factors apart from cost and distance, which

can be evaluated by a comprehensive study of the environment.

Barriers to Healthcare Access

Compared to other countries, African countries bear a greater burden of disease

and death from preventable and terminal causes (World Bank, 2011). WHO identified

lack of safe drinking water (58% of the population) and access to sanitation systems

(36% of the population) as contributors to these poor health outcomes (Information

Technology Associates, 2011). However, these poor health conditions also are due in part
 39

to the historical and current states of primary healthcare in Nigeria (National Primary

Health Care Development Agency, 2007). The following studies, organized in this

section according to Penchansky and Thomas’s (1981) five dimensions of access to

healthcare, support these dimensions as specific barriers to healthcare access.

Availability

Availability of healthcare services influences patients’ demand or use of those

services. Studies have shown that many factors influence patients’ demand for health

services in the community. Socioeconomic factors such as education and income (Higgs,

et al., 2001), availability of doctors, drugs, facilities, laboratories, and other healthcare

equipment (Onwujekwe, Chukwuogo, Ezeoke, Uzochukwu, & Eze, 2011), and

inadequacy of healthcare to community needs (Ladipo, 2009) all impact patients’ use of a

healthcare facility. These factors result in delays in seeking healthcare or obtaining

required services at the most appropriate time, and thus affect the healthcare use and

health-seeking behavior of rural residents (Cham et al., 2005). In a study in Tajistan, Fan

and Habibov (2009) found that the availability of physicians or qualified healthcare

providers was a determinant for healthcare use.

Accessibility

Distance to a healthcare facility may pose a problem to use and access of a

healthcare. Distance traveled to obtain healthcare may make the difference between life

and death and result in low health outcomes. Grzybowski, Stoll, and Kornelsen (2011),

who investigated the impact of distance on healthcare use among rural residents in

Canada, concluded that rural parturient women who have to travel to access maternity
 40

services have increased rates of adverse perinatal outcomes. In another study in South

Africa, Nteta, Mokgatle-Nthabu, and Oguntibeju (2010) sought to investigate the

relations between accessibility and healthcare use. The authors found that in the Tshwane

Region of Gauteng Province, South Africa the percentage “of use of a rural health facility

decreased with increasing distance: 45.3% (within 5km), 39.2% (less than 10 km), and

15% (more than 10 km)” (p. e13909). Other studies have found that close proximity to a

healthcare facility is an influential factor in the choice and use of a health provider

(Onwujekwe et al., 2010). Okeke and Okeibunor (2010) found, “In rural areas, the effect

of distance on service use becomes stronger when combined with the lack of

transportation and with poor roads, which contribute towards indirect costs of visits” (p.

67).

Accommodation

The manner in which a healthcare service system responds to people’s cultural,

social, and personal preferences ultimately determines whether people consider it

convenient to use or stay in the service. People seek healthcare in a place that recognizes

and accommodates their cultural values, sex, age, social circumstances such as time of

operation, and education (Liu & Dubinsky, 2000). Accommodation of peoples’

sociocultural preferences was determined to influence preference for traditional healers in

a study. Offiong (1999) concluded:

In a society where healing involves not just the curing of disease but also the

protection and promotion of human physical, spiritual, and material well-being,

traditional healers remain the very embodiment of conscience and hope in their
 41

respective communities. The holistic and cathartic nature of their treatment and

the fact that in certain places in the country they are the major or only source of

health care, make them very important. (p. 118)

Evidence shows that providers or healthcare facilities that offer alternative methods of

payment such as “compensation in kind or work” (Hausmann-Muela, Mushi, & Ribera,

2000, p. 276) increase access to such care. People will normally patronize a healthcare

facility that clearly understands them and accommodates their current circumstance in

healthcare delivery.

Affordability

The inability of people to pay for healthcare reduces their chances of using or

seeking services when sick. Poverty and the ability to pay have been shown by scholars

to influence healthcare use and access. The ability to pay, or level of poverty,

significantly determines when and where a person seeks healthcare (Abdulraheem, 2007).

In a cross-sectional study of 756 households, Abdulraheem (2007) sought to find the

determinants of health-seeking behavior among elderly people. The researcher found,

“Poverty reduced the odds of seeking health care from qualified medical practitioner but

increased the odds of using home remedies from the family and consulting patent drug

seller” (p. 61).

Onwujekwe et al. (2011) sought to determine the health-seeking behavior of

people with malaria in urban and rural areas of southeastern Nigeria. The authors

collected data using a multistage sampling method with a sample size of 400 households

from each study area. They found that “choice (of healthcare) is influenced by prices
 42

(including travel and time costs of seeking treatment), income, lack of information about

appropriate treatment and the difficulties patients have in assessing quality treatment”

(Onwujekwe et al., 2011, p. 94).

In a study of rural–urban differences in health seeking for treatment of childhood

malaria in southeast Nigeria, Okeke and Okeibunor (2010) sought to identify differences

in health-seeking behavior for childhood malaria treatment between urban and rural

residents. Using qualitative and quantitative methods, the authors sampled 1,200

caretakers of children less than 5 years of age for 2 weeks. They found that “cost of care

was one of the many factors preventing mothers from using orthodox medicine in rural

areas” (p. 66). Healthcare for rural populations can be translated to the cost of

transportation and feeding expenses while on a trip to the doctor (Okeke & Okeibunor,

2010). The cost of healthcare impacts the health-seeking behavior of the poor more than

the behavior of the more affluent populations. Poor people are more likely to seek

healthcare services if the cost of treatment is low and affordable than when they have to

pay high out-of-pocket costs (Grundy & Annear, 2010).

In a study to determine the relationship between health-seeking behaviors and

health systems, Hausmann-Muela, Mushi, and Ribera (2003) explained that, to a great

extent, “health-seeking of households depends on their capacity and possibility at a

specific moment to mobilize resources, both in material and social or symbolic terms”

(p. 21). According to Abel-Smith and Rawal (as cited in Hausmann-Muela et al., 2003,

p. 21), “even if direct costs are affordable, or if medical services are free, indirect costs

(for transport, special food, ‘under-the-counter’ fees) can limit access to treatment or lead
 43

patients to interrupt therapies.” Direct cost and indirect cost of healthcare play a big role

in when and how a client seeks healthcare. Indirect costs include transportation,

accommodation, and feeding, whereas direct costs are payments for doctor visits, drugs,

diagnostics, and supplies.

Acceptability

Clients perceive acceptability in the type of communication that transpires

between them and their healthcare provider (Asnami, 2009), as well as the extent to

which healthcare providers meet people’s social, cultural, or ethnic needs (Hausmann-

Muela et al., 2003). Acceptability has been found to be a key determinant in the choice of

general practitioners in a study among rural Australian residents (Humphreys, Matthews-

Cowey, and Weinand, 1997). Humphreys et al. (1997) concluded that healthcare will be

more acceptable to people if “the rural doctors acquire suitable clinical and

communication skills to meet the diverse needs of their patients, as well as an

understanding of rural culture” (p. 577). Indeed, patients will not accept a service that

alienates and disrespects them.

Community-Based Research as a Potential Tool for Change

Community-based research focuses on a topic relevant to the community, actively

involves community members in the research process, and promotes positive social

change (Centre for Community Based Research, 2011). The insufficiency or lack of

community input in healthcare delivery poses a great barrier to care and results in the

inequity of health outcomes and low outcomes from health expenditures (WHO 2008b).

Studies on perceptions using community-based research indicated that such research can
 44

promote community-based healthcare and improve health outcomes among various

populations (WHO 2007).

Rust and Cooper (2007) emphasized the importance of community-based research

and investigated how practice-based research contributes to the elimination of health

disparities. Their study established strategies that may improve access to healthcare and

reduce disparities in healthcare by recommending interventions that triangulate patients,

providers, and communities to improve health outcomes.

Providing healthcare through consumer input has been applauded by the WHO

(2007) as a tool to improve patients’ satisfaction and use of healthcare. Providing services

that meet community need has “been recognized as one of the six attributes of a health

care quality, the others being safety, timeliness, effectiveness, efficiency and equity”

(WHO, 2007, p. 5). Community-based research enhances bottom-up planning and

improves better commitment and participation in healthcare decision making (Few,

Harpham, & Atkinson, 2003). Wallerstein and Duran (2006) described community-based

participation as a new model and “an alternative research paradigm, which integrates

education and social action to improve health and reduce health disparities” (p. 312). In

spite of the great importance and role of community-based participatory research in

improving healthcare delivery through a collaborative effort of providers, researchers,

and community members, many problems work against its implementation. According to

the Agency for Healthcare Research and Quality (2009), factors such as insufficient

community incentives, insufficient academic resources, and inadequate funding and

funding mechanisms that are not sensitive to community involvement are among the most
 45

pressing obstacles. Community-based research is a novel idea to incorporate community

inputs in the policy, planning, and implementation of community-oriented healthcare.

Literature Related to Methodology and Methods

To present a unified discussion of the qualitative research tradition—including

justification for using the chosen paradigm and explanations of why other likely choices

would be less effective, as required by Walden University’s evaluative structure—

literature related to the methodology and methods is presented in this section.. In this

study, I used a qualitative, community-based research design and case-study approach to

explore the issue of healthcare access for the rural people of Isu.

Qualitative Research Design

Unlike quantitative research, which “explores traits and situations from which

numerical data are obtained” (Mertler & Charles, 2005, p. 386), qualitative data aim to

provide in-depth understanding of those traits and situations, in their natural setting

(Trochim & Donnelly, 2008). Qualitative research begins with assumptions, a worldview,

possibly using a theoretical lens, to investigate “the meaning individuals or groups

ascribe to a social or human problem” (Creswell, 2007, p. 37). Thus, qualitative research

is inductive, in contrast to quantitative research, which is deductive (Abusabha &

Woelfel, 2003). It “rests on the principle of subjectivity … [whereas] quantitative

research rests on the principle of objectivity” (Abusabha & Woelfel, 2003, p. 566). The

qualitative researcher is a participant and is immersed in the data-collection process, in

contrast to a quantitative researcher, who is removed and does not influence the data or

information collected (Abusabha & Woelfel, 2003). Unlike quantitative research,

 46

qualitative research does not seek to define rigid categories about populations or

conditions under study, nor does it make large generalizations (Abusabha & Woelfel,

2003, p. 566).

By using input from people who experience or suffer in a situation, a qualitative

research design is able to break the communication barriers that marginalize people from

participating or contributing in issues that affect them. Qualitative, community-based

research is collaborative because “it is inquiry completed ‘with’ others rather than ‘on’ or

‘to’ others” (Creswell, 2007, p. 22). This method of inquiry is appropriate to study a rural

community like Isu because it is “self-reflective, collaborative, empowering, and supports

actions for improvement” (Linville, Lambert-Shute, Frahauf, & Piercy, 2003, p. 210).

In this study, I explored the meaning of access to healthcare through the

theoretical lens of Penchansky and Thomas’s (1981) dimensions of access using

subjective, inductive-analysis coding of data to understand the specific conditions

associated with a limited population. Qualitative research was beneficial because it

allowed collection of data that cannot be quantified, such as emotions, facial expressions,

and environmental conditions (Yin, 2003). This characteristic was especially helpful in

Isu, where many residents potentially could have been unable to read and write. In

addition, qualitative research is beneficial because it positions the researcher as an

instrument of data collection (Creswell, 2007). This characteristic was especially helpful

in Isu where many residents may have been intimidated by data collection that lacked

personal connections and where storytelling is an accepted cultural phenomenon.

 47

A qualitative research design was chosen for this study because it was appropriate

to answer the research questions, engage participants in discussions that recall

experiences, and collaboratively share opinions on the issues that impact their access to

healthcare in Isu. Using a qualitative study approach also enabled me to collect data in

peoples’ natural setting—community halls—take field notes, record experiences,

transcribe, and write a comprehensive analysis of themes that emerged from the

interviews, and share findings with the people. It also was most suitable to describe issues

in detail that would not be possible using a quantitative study design. It provided an

opportunity for various participants, irrespective of their different levels of education, to

express themselves satisfactorily and engage in problems solving over the 5 weeks of the

study.

Qualitative research is not without drawbacks. For instance, conducting

qualitative research can be time consuming (Mehra, 2002; Trochim & Donnelly, 2008)

and can encourage researcher bias in data collection and analysis. However, the time

investment was insignificant in comparison to the wealth of knowledge I gained from

conducting this type of research. In addition, I believe the awareness of the potential for

researcher bias helped me avoid introducing bias into my study. Also, I believe using a

second coder and conducting debriefing and member-checking sessions with participants

helped me identify and eliminate bias in my study.

Case-Study Approach

According to Trochim and Donnelly (2008), a case study is an in-depth study of a

specific individual, group, or context. Creswell (2007) added that, regardless of the
 48

number of cases included, the exploration occurs in a bounded system (p. 73). Case

studies are used to inquire into other similar individuals, groups and contexts. They

typically involve the use of multiple methods of data collection, including interviews, as

well as the description, analysis, and presentation of data (Creswell, 2007; Yin, 2003) and

are used to gather in-depth data about “individual, group, organizational, social, political,

and related phenomenon” (p. 1). In this case study, I used multiple methods of data

collection (interviews and focus groups) to gather in-depth knowledge about a group of

people (rural residents of Isu) and related phenomenon (healthcare access).

Before deciding on the case-study approach for my research, I considered other

qualitative approaches, such as narrative, ethnographic, phenomenological, and

grounded-theory approaches. Narrative research relies on accounts shared by individuals

describing how they make meaning about a problem in their lives (Creswell, 2007). This

approach was inappropriate for my study because I collected data using specific interview

and focus-group questions to guide participant responses about particular experiences and

perceptions. Ethnographic research refers to research that is conducted over an extended

period and includes observation (Yin, 2003) for the purpose of describing a culture and

its shared values and beliefs (Creswell, 2007). This approach was inappropriate in my

study because I did not observe the participants, and I was limited by time. In addition, I

was not seeking to describe cultural values and beliefs but rather perceptions associated

with conditions of experience.

Phenomenological research refers to research that focuses on a defined common

experience or problem of a group of people (Creswell, 2007). This approach was

 49

inappropriate for my study because participants had varying experiences in their use of

healthcare services, a phenomenon which I purposely did not define during data

collection to promote the collection of a range of perspectives regarding the concept of

access to healthcare. Grounded theory refers to research that aims to develop a theoretical

foundation based on collected data (Creswell, 2007); this approach was not appropriate

because my intent was not to generate theory but to explore conditions as they existed

among participants and as they were expressed through participant perceptions.

A case study has the elements and characteristics to explore a world view of the

people of a population regarding a phenomenon under study: in the case of this study, Isu

and access to healthcare. It was effective in understanding Isu peoples’ perceptions about

the characteristics of the healthcare system that met or did not meet their healthcare

needs. It provided the people the opportunity to express their views freely in words and

emotions in their natural environment. A case study helps the researcher observe and

record emotional expressions of the people that would not be captured in a quantitative

study. In Isu, where little or no research has been done and not all people speak English, a

qualitative case-study approach became the most effective choice to interact and record

public views on an issue such as primary health care.

According to Yin, a case-study approach should be used when a study is focused

to address how and why, when the context of the problem is essential to understanding

the phenomenon, and to “gather extensive materials from multiple sources of information

to provide an in-depth picture of the case (Creswell 2007, p. 96). Case-study methods

have been used extensively in community-based prevention programs and are suitable for
 50

explaining perspectives of the actual people involved or affected by the phenomenon

(Tellis, 1997). To get a complete and true picture of healthcare access in Isu, a qualitative

case study was used to explore various dimensions of perspectives about access to

healthcare and to gather in-depth data. Using a qualitative case study ensures that issues

are not explored in a single viewpoint, but through several lenses that allow “for multiple

facets of the phenomenon to be revealed and understood” (Baxter & Jack, 2008, p. 544).

Summary

Healthcare, especially primary healthcare, is fundamental to the enjoyment of life

and improved productivity. The neglect or inadequacy of primary healthcare services,

especially to rural and the most vulnerable populations, has been a major problem

confronting the world. Traditional healthcare existed in Nigeria prior to colonial times.

The advent of colonialism was not only political and economic but impacted all aspects

of the lives of people, including healthcare. Colonization was antagonistic to the

traditional health system because traditional medicine did not conform to the Christian

beliefs colonialists brought to Africa and was a barrier to the introduction of Western

medicine and practice. Colonization thus decimated traditional healing, which was

centered on primary care and holistic health. The Western medical system was

discriminatory because it focused on the selective health of colonial employees and

colonialists, based in urban areas, to the neglect of the rural health infrastructure.

Many years of reforms and development plans did not yield meaningful solutions

to Africa’s health problems because they were not developed from the ground up. Access

to healthcare is not determined by the presence of a health facility alone, but by other
 51

social, economic, cultural, demographic, logistic, and geographic factors, as well the as

the availability of human and material resources, and above all, need. The mere fact that a

health facility exists does not mean people can access it. Access to health care must be

seen from the viewpoint of Penchansky and Thomas’ (1981) five dimensions to consider

all factors that may promote or inhibit healthcare access. To provide healthcare that meets

community needs, community input is required through community-based research to

identify problems, suggest solutions, and build community capacity to support and

sustain the program. This project will contribute significantly to the literature and fill the

gap in the literature regarding access to health care in Nigeria and in Isu in particular.

Concern for improving healthcare access has attracted individuals and

international attention with the important role played by the Alma Ata Declaration in

1978. Since Alma Ata in 1978, the WHO, UNICEF, and various regional governments

have embarked on reforms to improve healthcare and to achieve global health for all

people. Even though these efforts have been laudable, what is lacking in my country of

Nigeria, and in many other parts of Africa, is the inability to integrate community input

into health-policy planning, development, and implementation. Following, Chapter 3

describes the methods used to collect data for this study.

 52

Chapter 3: Methodology

The purpose of this qualitative case study was to explore the perceptions of rural

community residents and healthcare providers regarding residents’ access to primary

healthcare services in Isu and to engage in community-based research to demonstrate its

potential to promote resident access to healthcare services. In particular, the focus of this

study was (a) the residents’ perception of accessibility, affordability, accommodation,

acceptability, and availability of government healthcare services, and (b) the

characteristics of the healthcare system that hinder and promote residents’ use of

healthcare services.

This chapter includes a summary of the research design and approach, as well as

the rationale for the selected design and approach. Finally, this chapter includes a

detailed discussion of the data-collection process; data-collection tools; data-analysis

process, including research questions and expectations; and procedures put in place for

the protection of human participants.

Research Design and Approach

To investigate the phenomenon in this study, I designed the study in the following

ways. I identified the phenomenon under investigation and selected a community to be

studied. Then I chose a population and selected participants who would provide the

required responses to the research questions I designed. I collected data using focus group

and face-to-face interview techniques. Responses from participants were recorded and

analyzed as they related to specific questions, and I identified specific themes in the

study. The results of the data were presented to the participants to ensure validity and
 53

data accuracy. Finally, a detailed discussion of the results was conducted to explain the

perceptions of participants about access to health care in the Isu Local Government Area.

Research Questions

Research Question 1. What are the perceptions of healthcare providers

(government healthcare administrators, nurses/midwives, and traditional healers)

regarding residents’ access to and use of primary healthcare services provided in rural

Isu?

1a. What are healthcare providers’ perceptions regarding the characteristics of the

local government healthcare system that work well?

1b. What are healthcare providers’ perceptions regarding the main challenges and

barriers faced by the local government healthcare system?

1c. What are healthcare providers’ perceptions regarding solutions to the main

challenges faced by the local government healthcare system?

1d. What are healthcare providers’ perceptions regarding the potential for closer

relationships between the local government healthcare system and traditional

healers?

Research Question 2. What are the perceptions of local community members

regarding their access to and use of healthcare services in rural Isu? Specifically:

2a. What are residents’ perceptions regarding characteristics of the local

government healthcare system that fulfill residents’ needs?

2b. What are residents’ perceptions regarding the main challenges and barriers

faced by the local government healthcare system?

 54

2c. What are residents’ perceptions regarding solutions to the main challenges

faced by the local government healthcare system?

2d. What are residents’ perceptions regarding confidence in the local government

healthcare system and in traditional healers?

Research Question 3. What are the perceptions of healthcare providers and

residents regarding community-based research as a means of promoting the use of

healthcare services among the rural residents of Isu?

Role as a Researcher

As the researcher, I was the key instrument of data collection. For the purpose of

this study, and as indicated by Creswell (2007) and Fink (2000), I served as an interface

for interactions between participants who experienced the problem or phenomenon under

study. I was responsible for designing semistructured interview questions and meeting

with the participants to conduct individual interviews with healthcare administrators and

to conduct focus groups with nurses and midwives, residents, and traditional healers in

their local communities. In addition, I made assumptions, set delimitations, and analyzed,

interpreted, and presented the data. As suggested by Yin (2003), to indicate the accuracy

of the evidence, I used multiple sources to collect data on participant perceptions about

healthcare delivery in Isu. Because qualitative research involving a human element such

as the researcher and participants is subject to bias, to validate the data, I considered its

credibility, dependability, confirmability, and transferability.

Qualitative research may be open to human or researcher bias due to influences

such as prejudice and personal beliefs (Abusabha & Woelfel, 2003). To address this
 55

problem, I adhered to good conduct and behavior during the interview. As recommended

by Fink (2000) and Trochim and Donnelly (2008), I (a) did not indicate agreement or

disagreement with participants during the interviews; (b) did act as an active observer,

listener, and recorder; (c) did record only the expressed opinions of the participants;

(d) drew conclusions inductively from observations; and (e) summarized findings,

identified patterns, and corroborated all information to form an accurate representation of

participant perspectives.

Setting

This study was conducted in Isu, Imo State, Nigeria. Based on characteristics

identified by Umebau (2008), such as low income and poor infrastructure (conditions that

facilitate various observable social, economic, and environmental issues), at the time of

this study, Isu could be considered a rural community—one of the 774 local government

areas in the 36 states of Nigeria and one of 27 local governments in Imo State (Embassy

of the Federal Republic of Nigeria, 2011)—a southeastern region of Nigeria (Okafor &

Fernandes, 1987). Currently, Isu is made up of 13 autonomous communities and covers

an area of 221 square kilometers (Tulsi Chanrai Foundation, 2007). Its geography

comprises vast areas of flat land suitable for farming staple foods such as yams, coco-

yams (taro), sweet potatoes, cassavas, and a variety of vegetables, as well as maintaining

a variety of trees indigenous to the area (palms, iroko, coconuts, oil-bean, raffia, bamboo,

and mahogany; Okafor & Fernandes, 1987). As a result of land excavation and

deforestation, the area suffered from a serious erosion problem (Igbokwe et al., 2008) that

(a) contaminated water supplies (Hudec, Simpson, Akpokodje, & Umenweke, 2006),
 56

(b) led to the destruction of houses and roads (Igbokwe et al., 2008; Hudec et al., 2006),

and (c) promoted the proliferation of mosquitoes (Oladepo, Tona, Oshiname, & Titiloye,

2010).

In addition, Isu suffers from what Umebau (2008) referred to as urban bias: the

concentration of allocated social amenities (health access, transportation, and job

opportunities) in urban areas. For example, based on my personal observations (no

government records are available about these details), Isu had very little government

presence apart from the local government headquarters, a local police station, a motor

vehicle-licensing post, a post office, six middle schools, and 16 elementary schools. In

addition, administrative positions in healthcare planning are appointed and often

politically motivated, and government healthcare administrators might not be residents of

Isu or rely on local government healthcare facilities for healthcare services. For these

reasons, government healthcare administrators might not have had firsthand experience

with residents in the community and their healthcare needs.

Healthcare in Isu is based on the Ward Minimum Healthcare Package. As a means

of delivering affordable and accessible healthcare to remote populations, in 2000, the

National Primary Healthcare Development Agency introduced the Ward Minimum

Healthcare Package, which describes a set of priority health interventions “that should be

provided in primary health care centers on a daily basis at all times” (World Bank &

Inter-American Development Bank, 2008, p. 14) but also subsidized by government

funding so there is no or little cost to users (National Primary Health Care Development

Agency, 2007). The updated 2007 Ward Minimum Healthcare Package used in Isu
 57

includes an outline of basic intervention areas in which primary healthcare systems were

encouraged to concentrate and achieve in full by 2012, including (a) control of

communicable diseases (malaria, STI/HIV/AIDS), (b) child survival, (c) maternal and

newborn care, (d) nutrition, (e) incommunicable-disease prevention, and (f) health

education and community mobilization (World Bank & Inter-American Development

Bank, 2008, p. 14).

Although the Minimum Healthcare Package staffing guidelines do not include

medical doctors, the guidelines do indicate that health posts should have on staff one

junior community-health extension worker (CHEW); primary healthcare clinics should

have on staff two CHEWs and four junior CHEWs; and ward health centers (primary

healthcare centers) should have on staff one community-health officer, one public health

nurse, three CHEWs, six junior CHEWs, three nurses/midwives, and one (optional)

medical assistant (National Primary Health Care Development Agency, 2007). In

addition, the Minimum Healthcare Package includes guidelines related to equipment,

drugs, infrastructure, and services for the primary health center (World Bank & Inter-

American Development Bank, 2008).

Despite these guidelines, healthcare services are minimal. According to the most

recent literature available, the government supports one hospital and an estimated 17

healthcare facilities: four functioning healthcare clinics (one primary healthcare center

and three community health centers) and 13 healthcare posts in the local communities

Tulsi Chanrai Foundation, 2007). The healthcare posts are locations established for the

intermittent implementation of health-education programs (and may be a private, donated

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space) such as those pertaining to disease management or healthcare programs such as

vaccine distribution. These facilities offer limited hours of operation during the week

(Nigerian High Commission, 2011); there are no provisions for physicians, laboratories,

pharmacies, or emergency services (Adeyemo, 2005). Based in part on the lack of

available government healthcare services, residents often turn to private-practice

providers (Adeyemo, 2005) and traditional healers (Onwujekwe et al., 2011) for

healthcare services.

Isu, as part of Nigeria, is characterized by poor socioeconomic conditions.

According to the World Bank (2004a), 54.7% of Nigerians live below the national

poverty line. The Federal Office of Statistics indicated the percentage to be much higher

(70%; Omarioghae, 2008). This condition, however, is more prevalent in rural areas than

in any other areas (Cohen et al., 2007).

As of 2006, Isu had a population of 164,328 people: 84,299 (51.3%) males and

80,029 (48.7%) females (National Population Commission, 2010). According to

Chukwuezi (2001), the majority of younger males from rural areas tend to leave to go to

school or migrate to urban areas to learn trades or become street vendors. Consequently,

the residents of rural Isu tend to be predominantly young children, unemployed teenage

girls, and old adults. Adults who remain in these areas tend to be either those

incapacitated by ill health or those who survive as traditional healers, subsistence

farmers, or petty traders. Sale of farm produce and petty trading of household items

constitute the major source of income for the residents. The people of Isu predominantly

speak Igbo. The population as a whole regards the family system with high esteem
 59

(Ufearoh, 2010), is highly social, and is highly religious (Chukwuezi, 2001). The

majority of the people of Isu are of the Christian faith (Chukwuezi, 2001).

The participants in this study provided a clear description of the local setting with

regard to healthcare facilities in Isu. According to healthcare providers who participated

in this study, in Isu, there are three health posts, eight health centers, and two primary

healthcare centers. Health posts do not have a regular staff and are mobilized as the need

arises. Typically, health posts are staffed by one junior CHEW.

Health centers, also known as community health centers, are located in

community built facilities and serve entire communities. However, residents of the local

government are free to visit any community health center at any time. The community

health centers are headed by either a registered nurse or midwife, or a CHEW. None of

these health centers meets the minimum staff requirement indicated by the National

Primary Healthcare Development Agency.

Primary healthcare centers, also known as Ward health centers, may or may not

be located in community built facilities, although they do serve as a community-based

health facility. Primary healthcare centers include a more diverse staff and offer more

diverse services. For example, in addition to general services, primary healthcare centers

also include a maternal–child healthcare unit.

Study Participants

Participants for this study were healthcare providers and residents. Healthcare

providers included healthcare administrators indirectly involved in providing healthcare

services to the residents of the community, nurses/midwives, and traditional healers

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directly involved in providing healthcare services to the residents of the community.

Health administrators are the local government chairman and two other senior officials in

the local healthcare system. Because the Isu Local Government Area chair oversees all

aspects of the Isu Local Government Area including the primary healthcare system, for

the purposes of this study, I considered the local government chair a healthcare

administrator and included the chair in this study as a healthcare provider. Nurses and

midwives were trained in Western medicine and understand the nuances of specialized

medical certification. The other group of participants was residents who depend on the

local health system for service and have some experience using the health system. To

conduct this study, I chose and interviewed 27 participants: three health administrators,

six nurses/midwives, six traditional healers, six female adult residents, and six male adult

residents.

Sample

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria for participants in this study varied based on

participant type. However, all participants were required to be of legal age (18 years and

older) to participate in the study. Typically, the age of government healthcare

administrators, nurses and midwives, and traditional healers is 30 years or older. In

addition, participants must have been willing and able to give informed consent and

participate fully in all aspects of the study. No potential participants were excluded on the

basis of race or gender.

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Government Healthcare Administrators: Only those administrators who held

senior administrative or leadership positions in the health department or a position

directly involved in healthcare decision making at the local government level were

eligible to participate in this study. This criterion helped ensure that only those

thoroughly knowledgeable about all aspects of the government healthcare system were

recruited for this study and thus, that I collected, as well as possible, the most accurate

and detailed data about the conditions of the government healthcare system.

Administrators also must have worked in this described capacity for at least 3 years. This

criterion also helped ensure that these participants were knowledgeable about all aspects

of the government healthcare system. Because government healthcare-administrator

positions are political appointments, they are subject to change based on the political

conditions of the area, which typically are dynamic. Thus, I chose a 3-year time frame to

increase the likelihood of recruiting eligible government healthcare administrators.

Because the functions associated with government healthcare administration

currently are not reliant on administrator/resident contact or relationships, administrator-

residency status was not considered an inclusion or exclusion criterion in this study. With

regard to inclusion criteria and so that I could collect data from anyone who was serving

as the active chair during the time of my data collection, I did not restrict the years of

service for the local government chair (considered a healthcare administrator for the

purposes of this study). Regarding nurses and midwives, only those nurses who currently

were working in government-supported healthcare facilities and midwives who were

working either in government-supported healthcare facilities or in private practice,

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providing healthcare services to residents in the local area, were eligible to participate in

this study. This criterion helped ensure the recruitment of participants who best reflected

my intended population of healthcare providers—those who work with the residents of

rural Isu. Eligible nurses and midwives were licensed to practice and had no less than 3

years’ experience providing direct healthcare services. This criterion helped ensure that

these participants were knowledgeable about the government healthcare system as well as

familiar with the residents they served. Because nurses and midwives are certified

professionals, they are in a position to and tend to move around regularly based on

availability of work. For this reason, I chose a 3-year time frame to increase the

likelihood of recruiting eligible nurses and midwives. I excluded nurses who worked at

the government hospital because typically, they do not work with the community

residents who were the focus of this study.

Traditional healers: Only those who had been residents of Isu and served the local

population for 5 years were eligible to participate. This criterion served to help recruit

traditional healers who were familiar with the local government healthcare system as well

as familiar with other residents. Also, to ensure that I recruited traditional healers who

could share their perspectives on past experiences, I excluded traditional healers who

indicated that they were unable to recall experiences related to their provision of

healthcare to residents.

Residents: Only those who were familiar with the local government healthcare

system and had been active residents of Isu for at least 5 years were eligible to participate

in this study. This latter criterion helped ensure that recruited residents were familiar with
 63

the local government healthcare system. To decrease the chance of cross-contamination

of group participant type, I excluded residents if they worked as government healthcare

administrators, nurses or midwives, or traditional healers. Finally, to ensure that I

recruited residents who could share their perspectives on past experiences, I excluded

residents who indicated that they were unable to recall experiences related to their use of

or choice not to use available government healthcare.

Participant Selection and Recruitment

In qualitative research, the sample size is not intended to be representative of the

population, but rather to establish an in-depth understanding of the population in relation

to the research questions posed (Marshall, 1996). According to Onwuegbuzie and Leech

(2007), a sample for qualitative study should not be “too large that it is difficult to extract

thick, rich data or too small that it is difficult to achieve data saturation” (p. 242). As a

general rule, Onwuegbuzie and Collins (2007) recommended a sample size of 12

participants for interviews and between three and 12 participants for focus group

discussions. Based on time constraints imposed as the result of my travel to Nigeria to

collect data, I determined to accommodate no more than three health administrators, six

nurses and midwives combined, six traditional healers, and 12 residents in my study. I

calculated that the perspectives and opinions of 27 participants selected from Isu would

be able to provide reasonable data to understand the issues related to healthcare access in

the Local Government Area.

I used purposive sampling methods. Purposive sampling is a nonprobability

sampling method that is used when a researcher aims to gather perspectives of a

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particular group of people (Babbies, 2010; Trochim & Donnelly, 2008, p. 49). The

sample represents a choice of participants based on their knowledge and experience of

the concept under investigation in the study (Babbie, 2010; Creswell, 2007;

Polkinghorne, 2005). Because the success of my study depended on the perspectives of

participants, in particular those with knowledge and experience specific to primary

healthcare access in rural Isu, it was imperative that I selected only participants with this

knowledge and experience. For that reason, the use of purposive sampling was

appropriate for my study.

I recruited participants for my study in several ways based on the type of

participant being recruited. To recruit government healthcare administrators, I contacted

the Chairman in charge of Isu local government who also is in charge of the local primary

health system, and requested his participation in the study (purposive). To recruit

additional healthcare administrators, I sought from the Chairman a list of potential

participants in the health department who met the inclusion criteria and whom I might ask

to participate in interviews. I conducted this recruiting at the local government

headquarters in Umundugba, Isu.

To recruit nurses and midwives employed by the local government, midwives in

private practice, traditional healers, and residents, I (a) had flyers posted (see Appendices

A, B, and C for the original flyer, the translated flyer, and the back translation,

respectively) in healthcare and community centers, and in other public spaces before my

arrival to Nigeria, and I posted additional flyers upon my arrival, (b) asked pastors to

distribute flyers to their parishes, (c) held open informational meetings to introduce
 65

myself and the purpose of the study, and (d) networked individually with people in the

community (purposive). For the convenience of participants, I conducted meetings for

(a) nurses and midwives at the local government headquarters in Umundugba,

(b) traditional healers at the traditional healers’ hall in Ekwe, and (c) residents in the

community center in Nnerim. I held four informational meetings for recruitment purposes

prior to conducting the focus groups (two in English for nurses and midwives and two in

Igbo for traditional healers and residents, with translation as needed for individual

participants in either group). Also, I asked community leaders and pastors to suggest

potential participants I might ask to participate in the study (purposive). In addition, I

asked all potential participants who attended informational meetings and/or whom I

spoke with personally to share information about the study with residents they knew who

may have had extensive experience with the primary healthcare system in Isu and thus be

able to offer valuable insight to the study (snowball).

Data Collection Tools

I used instruments I developed to collect data for this study. To ensure the

appropriateness of my interview and focus-group questions, I sought feedback from two

qualitative research experts and made changes as suggested. As suggested by Kohrt et al.

(2011), I ensured that the questions reflected the cultural and environmental setting of the

study and could be understood by the participants (clear and unambiguous) so that

participant responses would accurately reflect their perspectives about conditions in Isu.

As suggested by Onwuegbuzie and Leech (2007), I also continuously monitored and

 66

assessed the instrument throughout the interview progresses and made adjustments as

necessary to fit participants’ needs.

Because it was possible that some traditional healers and residents might not

speak English (fluently or at all), I collected data from these participants in both English

and the participants’ local language, Igbo, as necessary. Because I am fluent in both the

written and oral form of the language, I translated the questions and responses from Igbo

to English and vice versa for participants who may have had difficulty expressing views

clearly in English.

I used interview questions to collect data from government healthcare

administrators (see Appendix D), and used focus-group questions to collect data from

nurses and midwives (see Appendix E), traditional healers (see Appendices F, G, and H

for the original questions, the translation, and the back translation, respectively), and

residents (see Appendices I, J, and K for the original questions, the translation, and the

back translation, respectively). I organized the interview questions and focus group

questions by the research question they helped answer.

The interview questions for the government healthcare administrators, nurses and

midwives, and traditional healers supported Research Questions 1 and 3 and focused on

(a) how the healthcare system currently functions, (b) solutions to overcome identified

challenges and barriers to healthcare implementation, (c) the role of traditional healers in

the healthcare process, and (c) the value of community-based research. The focus group

questions for residents supported Research Questions 2 and 3 and focused on

(a) residents’ use and perceptions of available healthcare services, (b) the effectiveness of
 67

available healthcare services, (c) solutions for overcoming identified challenges and

barriers to healthcare access, and (d) the value of community-based research.

Data Collection

Prior to collecting any data, however, I sought approval from the appropriate

authorities. Specifically, I sought approval from Walden University’s Institutional

Review Board to conduct my study (07-06-12-0065704) and the Chairman of Isu to

interview the chair and several key officials involved in healthcare planning (see

Appendix L). I also sought support from local community leaders, pastors, and the leader

of the local traditional healers (see Appendices M and N). Two local community leaders

provided letters of support prior to data collection (see Appendix O). I collected data

from residents and healthcare providers using a combination of interviews and focus

groups over the course of 11 days (see Appendix P, Days 1–11). Although focus groups

and interviews do not support the collection of data from as large a number of

participants as do surveys, because my intent was to explore details associated with my

topic rather than to seek broad insight, these data collection methods were appropriate for

the study (Creswell, 2007).

Interviews

I conducted face-to-face interviews to collect data. According to Yin (2003), an

interview is a qualitative tool for collecting information or data and can be either

unstructured (without a plan for directing data collection), semistructured (with a plan for

collecting data using open-ended questions and allowing for probing), or structured (with

a plan for collecting data without allowance for probing). The interviews were
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semistructured, which, according to Yin, indicates the use of open-ended questions to

probe the how and why behind conditions, perceptions, or experiences. I chose this

method because it promotes the opportunity to ask immediate follow-up questions to

clarify issues (Trochim & Donnelly, 2008); an advantage unavailable with questionnaires

in quantitative study methods. Also, this method was appropriate for interviewing the

government healthcare administrators so that lower level administrators might feel

comfortable speaking freely without fear of disciplinary action or intimidation for voicing

concerns about the government and its healthcare system.

According to Creswell (2007), the quality of data collecting using interviews

depends to a great extent on the framing of the interview questions and the experience of

the interviewer in recording and transcribing information from the interview. In addition,

the presence of an interviewer may influence the opinion or expression of perceptions of

study participants (Trochim & Donnelly, 2008). To ensure the highest possible quality of

collected data in this study, I sought feedback from experts in the field regarding the

appropriateness of my interview questions and made adjustments as needed. In addition, I

was born in Isu and, based on my personal understanding of the cultural and social beliefs

and practices of the people of Isu, I anticipated that my presence as an interviewer would

enhance my ability to collect accurate and thorough expressions of participant

perceptions.

I began data collection by interviewing the chair of Isu and two other government

healthcare administrators using semistructured interview questions. I conducted the

interviews at the local government headquarters in Umundugba in private offices or a

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private conference room provided by administrators. I asked for their permission to

record our discussion. When participants offered information that was unclear or

incomplete, I prompted participants for clarification and additional details. If a participant

offered information that was not solicited but was relevant to the topic, I prompted the

participant to provide additional details as appropriate. After I completed the individual

interviews, I began conducting focus-group sessions.

Focus Groups

Another method of collecting data in a case study and one that I used in my study,

is the focus group. Trochim and Donnelly (2008) defined the focus group “as a

qualitative measurement method where input on one or more focus topics is collected

from participants in a small-group setting where the discussion is structured and guided

by a facilitator” (p. 120). According to Yin (2003), the focus group is an essential tool for

collecting information from various individuals or groups for the purpose of converging

evidence into a set of findings.

The focus group also is useful for improving participant interactions, conserving

time (Creswell, 2007), and generating “detailed information about attitudes, expectations,

opinions, and preferences of selected groups of participants” (Trochim & Donnelly, 2008,

p. 148). According to Gibbs (1997), focus-group research is beneficial in that it helps the

researcher gain insight into participants’ shared experiences and understand conditions

associated with a specific problem.

According to Abusabha and Woelfel (2003), the outcome of focus-group research

depends on the expertise of the facilitator and the facilitator’s ability to moderate the
 70

group successfully. In addition, members of a focus group may be influenced by the

presence of the researcher and may not be confident sharing their opinions (Trochim &

Donnelly, 2008). However, because I have worked in supervisory positions, including

positions requiring the organization of groups during community-development projects

and served as both a religious preacher in the community and president of the local

students’ union, I felt confident that I would be able to manage my small focus groups. In

addition, I anticipated that separating focus groups by general characteristics of

participants (nurses and midwives, traditional healers, male residents, female residents)

would promote the comfort level of participants and promote discussion in the groups.

Finally, because I am familiar with the people in the area, I anticipated that their comfort

level in the focus groups would be facilitated rather than hindered by my presence.

I conducted four focus groups: (a) nurses and midwives (at the local government

headquarters, Umundugba), (b) traditional healers (at the traditional healers’ hall, Ekwe),

(c) male residents (at the community center, Nnerim), and (d) female residents (at the

community center, Nnerim). I chose to divide the residents by gender to promote sharing

by women who might otherwise have felt it was inappropriate to express opinions unlike

those expressed by male residents from the community. I sought the consent of all

participants to digitally record our discussions.

For each group, I assigned each participant a unique number. The participants

wore identification badges with these numbers displayed. When participants responded to

focus-group questions or made comments to one another, I identified who was speaking

by calling out the participant’s number into the digital recorder. I used prepared focus-
 71

group questions to prompt participants to elicit information. When participants offered

information that was unclear or incomplete, I prompted participants for clarification and

additional details. If a participant offered information that was not solicited but was

relevant to the topic, I prompted the participant to provide additional details as

appropriate. I encouraged all participants to share their perspectives and worked to

provide equal opportunities for each participant to share. I determined data saturation

when I was no longer collecting new data and ended the focus groups at that time.

Data Analysis

Once all data were collected, I used Colaizzi’s seven-step phenomenological

method for analyzing qualitative data (Colaizzi, 1973, 1978). I used this method because,

according to Colaizzi (1978), it is suitable for analyzing the perceptions of people

regarding a phenomenon under study. Because the primary purpose of this case study was

to develop an in-depth understanding of the perspectives of healthcare providers and

residents in Isu, I used phenomenological data analysis approach to helped me understand

those perspectives. This seven-step method is similar to those described in Creswell

(2007) and Babbie (2010), but appeared simpler to understand:

1. Collect participant’s descriptions of the phenomenon, access to healthcare.

The researcher reads and rereads all the participants’ descriptions and

metaphors of the phenomenon to attain a sense of the whole.

2. Extract significant statements in relation to participants’ perceptions about

access to primary healthcare in Isu. Significant statements are extracted from

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the original transcripts that together form the whole meaning of the

phenomenon under investigation.

3. Formulate meanings. Significant statements are to be spelled out by the

researcher. The researcher also is to formulate more general restatements and

meanings for each significant statement from the transcript.

4. Organize formulated meanings into clusters of themes. The researcher is to

find clusters that are common to all participants’ experiences. Clusters are

arranged from formulated meanings. (In this study, I organized theme clusters

based on my research questions and Penchansky and Thomas’, 1981, five

dimensions of healthcare access.)

5. Exhaustively describe the investigated phenomenon. The researcher writes an

exhaustive description of the phenomenon under investigation.

6. Describe the fundamental structure of the phenomenon. The researcher

reduces the exhaustive description into an essential structure of the

phenomenon.

7. Return to the participant. The researcher validates the findings with the

participants, which may allow participants to clarify or reveal new data and

ensure that inclusion of their intended meaning was conveyed in the

fundamental structure of the phenomenon under study.

Before returning to participants to validate my findings, I engaged a second coder

to determine intercoder reliability of the data. I asked the second coder to code

approximately 20% of the transcribed data using Colaizzi’s (1973, 1978) seven-step
 73

method to organize formulated meanings into clusters of themes. Then, to identify

potential weaknesses and discrepancies in my data interpretation and analysis, I

compared with the second coder the various theme clusters the second coder and I

developed. Finally, I made adjustments to the theme clusters based on discussion with the

second coder, as I deemed appropriate.

According to my planned schedule, I met with the chair, other healthcare

administrators, nurses and midwives, traditional healers, and residents (in gender-specific

groups) to debrief them. I met each of the government healthcare administrators and the

group participants in the same location in which the initial data-collection meetings took

place. As indicated by Trochim and Donnelly (2008) and Yin (2003), this debriefing

consisted of a review of my preliminary analysis based on the data I collected. Then, I

conducted member checking (Colaizzi’s Step 7, 1973, 1978). Member checking consists

of providing study participants the opportunity to reject, confirm, or make corrections to

data shared during debriefing (Trochim & Donnelly, 2008; Yin, 2002). Finally, I made

adjustments to the theme clusters as I deemed appropriate, based on the feedback from

the participants and further consideration of the data.

I present my findings in Chapter 4 in narrative form and in data tables, as

appropriate. Specifically, I present my findings organized by research question and

dimension of healthcare access. My interpretation of findings represents all data,

including discrepant and nonconforming data.

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Ensuring Validity and Reliability in Qualitative Research

With regard to research in general, Trochim and Donnelly (2008) defined validity,

inclusive of reliability, as “the best approximation to the truth of a given proposition,

inference, or conclusion” (p. 20). However, definitions of validity often differ based on

the type of research to which they are applied. Because I conducted qualitative research

based on observation, I propose my analysis approximates the truth based on Lincoln and

Guba’s explanation of validity as it applies to qualitative research (as cited in Creswell,

2007).

According to Lincoln and Guba, validation of findings is less appropriate when

discussing observations than the establishment of confidence and trustworthiness in one’s

findings (as cited in Creswell, 2007). To establish such trustworthiness, Lincoln and

Guba suggested examining one’s findings with respect to credibility, transferability,

dependability, and conformability (as cited in Creswell, 2007, pp. 202–203). These

approaches, according to Creswell (2007), parallel traditional approaches used in

validating quantitative studies. Therefore, I used these approaches to plan for valid study

outcomes. I discuss the validity of my actual study outcomes in the Results section

following the presentation of my results.

Credibility refers to establishing the believability of findings from the research

participant’s perspective (Trochim, 2006; Trochim & Donnelly, 2008). In this study, as

indicated by Trochim (2006) and Trochim and Donnelly (2008), I established credibility

through prolonged engagement with participants in the field and providing a vivid

description of the data. Also, I established credibility by triangulating my data, that is,
 75

collecting data from multiple sources (government healthcare administrators, nurses and

midwives, traditional healers, and residents). In addition, I also improved the credibility

of my study findings through participant engagement in the data-analysis process (i.e.,

debriefing and member checking).

Transferability refers to “the degree to which the result of the qualitative study

can be generalized or transferred to other contexts or settings” (Trochim, 2006,

Qualitative Validity section, para. 4). Although the results of my study cannot be

generalized to other populations, by providing a thorough and accurate description of my

study methodology, processes, assumptions, and limitations, I have improved the chances

that another researcher may benefit from the transfer of concepts depicted in my results to

other study conditions and populations.

In quantitative research, the concept of dependability refers to a study’s capacity

to be repeated by other researchers in other locations and under other conditions using

similar measures (Trochim, 2006, Qualitative Validity section, para. 5). In qualitative

research, which lacks measurement, this concept more accurately applies to the setting in

the study—specifically, the researcher’s responsibility for describing any changes that

occurred during the course of the study and how those changes affected the researcher’s

approach to data collection and analysis (Trochim, 2006). To this end, I included in my

final document thorough explanations of all adjustments made to data-collection

procedures and preliminary data analysis, as appropriate.

Confirmability “refers to the degree to which the results could be confirmed or

corroborated by others” (Trochim, 2006, Qualitative Validity section, para. 6). I

 76

established confirmability by checking the data during my data-analysis process. I

checked data by using a second coder to determine intercoder reliability, and also by

conducting participant debriefing and member-checking sessions.

Protection of Human Participants

To protect the participants in this study, I conducted my study meeting all

standards of ethical research practices. Prior to beginning work on this study, I completed

the National Institutes of Health online course Protecting Human Research Participants

(see Appendix Q). I reviewed and conformed to the provisions in the National Code of

Health Research (2007) for doing research in Nigeria. In addition, the second coder, who

also helped transcribe data, signed a confidentiality agreement (see Appendix R). Also,

only participants who were of legal age to consent to participation were allowed to

participate in this study. In addition, no participant was enticed or coerced to participate

in any way, and all participants were asked to sign an informed consent in their respective

languages, indicating in clear terms and language the purpose of the study and the

expectations of participation in the study. In addition, the consent form indicated the

voluntary nature of the study, the risks and benefits of participating in the study, and the

lack of compensation for participation in the study. Finally, the consent form indicated

procedures to maintain participant confidentiality and offered contact information for my

advisor, the Walden University research participant advocate, and me, should participants

have questions after the study concluded.

The consent form for the healthcare administrator interviews is presented in

Appendix S). Because some traditional healers and residents may not have spoken
 77

English (fluently or at all), I presented the consent form for focus groups (see Appendix

T) in Igbo as well (see Appendices U and V for the translated consent form and the back

translation, respectively).

I maintained participant confidentiality during and after the study in multiple

ways. For example, I identified participants by an arbitrary participant number and kept

their names separate from all collected data during all stages of data collection, analysis,

and storage. While in Nigeria, I stored electronic files on a password-protected laptop

computer, which I kept locked in a private room in my temporary residence when not in

my immediate possession. I secured hard copy and digitally recorded data in a locking

cabinet in a local community leader’s office. When I returned to the United States, I

transferred electronic data to my password-protected home computer, which remains in

my secured home office. I will continue to secure hard copy and digitally recorded data in

a locked file cabinet in the same location for 5 years, after which time I will destroy it.

Summary

In this study, I used qualitative research methods to explore the issue of healthcare

access for the rural people of Isu. Data were collected in two ways: interviews and focus

groups. To ensure that various perspectives on the topic were considered, I used four

data-collection instruments. To analyze my data, I used Colaizzi’s (1973, 1978) seven-

step method for coding data. This process allowed me to identify the themes and patterns

of perspectives among participant responses. To demonstrate the reliability of my data

analysis, I triangulated my data by (a) collecting data from four types of participants

(government healthcare administrators, nurses and midwives, traditional healers, and

 78

residents), (b) using two types of data-collection methods (interviews and focus groups),

and (c) using four data-collection instruments to gather various perspectives regarding the

topic. In addition, I engaged a second coder to establish intercoder reliability and

conducted debriefing and member-checking sessions with participants.

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Chapter 4: Presentation of Results

The purpose of this study was to explore the perceptions of rural-community

residents and healthcare providers regarding residents’ access to primary healthcare

services in Isu Local Government Area, Imo State, Nigeria and to engage in community-

based research to demonstrate its potential to promote resident access to healthcare

services. In this chapter, I present data I collected from 27 healthcare providers and

residents using personal interviews and focus-group discussions, then analyzed using

Colaizzi’s (1973, 1978) seven-step method for analyzing phenomenological data and

cataloging emerging themes (see Chapter 3). I present the participants’ demographic

information first followed by a thorough discussion of themes grouped by research

question and dimensions of healthcare access. My interpretation of findings represents all

data, including discrepant and nonconforming data. I also provide a summary of results

and evidence of quality of my study.

Demographic Data

As shown in the Table, a total of 27 participants made up the sample in this study:

three healthcare administrators (including the local government chairman), six

nurses/midwives, six traditional healers, and 12 residents. The participants varied in age

(33–78 years). They also differed in socioeconomic status, but all—with the exception of

one administrator—reported living in the same community.

Of the three healthcare administrators, all had either college degrees or a nursing

certification. One administrator had 6 years of experience; another had 10 years of

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experience. The administrators had served in various functions, including counseling

positions and health planning. Two administrators lived in the community they served.

Table

Participant Demographics

Health care Nurse and/or Traditional

administrator midwife healer Resident
Variable (n = 3) (n = 6) (n = 6) (n = 12)

Gender

Male 2 4 6

Female 1 6 2 6

Education: highest level completeda

College 2 1 4

High school 2

Middle school 1 2

Elementary school 2 4

Registered nurse and/or midwife 1 6

Traditional healer 2

Age

30–40 1 3 3

41–50 2 2

51–60 2 1 1 3

61–70 1 1

71–80 1 3
a
Some traditional healers indicated other levels of traditional education, thus participant demographics may
represent more than 100% of the total study population.

The six nurses/midwives were directly involved in primary healthcare delivery in

the local government. All six nurses/midwives held certifications as either a registered

nurse or midwife (see the Table). Their ages ranged from 31 to 51 years. Each had more
 81

than 3 years’ work experience in the local-government primary-healthcare system. They

were all women. At the time of this study, all were heading or had headed a community

or primary healthcare center in the local-government primary-healthcare system.

Of the 12 residents, six were men and six were women. The residents’

occupations varied but included three subsistence farmers, three teachers, five petty

traders, and one retired civil servant. The residents all had at least one child and were

either married or widowed. All the residents used and depended on healthcare services in

the community.

The six traditional-healer participants had practiced traditional medicine for an

average of 10 years and not only claimed competency in general services but claimed

expertise in specialty areas as well. General services included treatment for malaria,

typhoid, stomach ache, constipation, convulsions, and whooping cough. Some specialty

areas included sexually transmitted diseases (often gonorrhea); fertility and miscarriage

issues including bleeding, bites, and poisonings, fibroids, devilish or spiritual attacks,

schizophrenia (commonly called madness), and spleen disease.

In the following sections, I present the theme clusters that represent the study’s

research questions. There are six theme clusters. I have categorized the 27 themes that

make up the theme clusters using Penchansky and Thomas’s (1981) five dimension of

healthcare access.
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Theme Cluster 1: Characteristics of the Local Government Healthcare System That

Work Well

In Research Questions 1a and 2a, healthcare administrators, providers, and

residents were asked about what characteristics of the local government healthcare

system work well or met community needs. Four themes emerged from their responses:

Availability

Theme 1: Effectiveness of services. Several participants reported healthcare

services had been able to reduce or prevent some deaths and sickness of children by

making immunization accessible (when available) to the children in the community.

Nurses/midwives and residents agreed that some incidences of deaths and mortality have

been prevented because healthcare providers bring vaccines close to them, and residents

do want to know when such vaccines are available for their children. Traditional healers

(66.6%) agreed that local immunization of children by the health system has been helpful

in preventing deaths and diseases of children. Participants (8, 16, 21, and 27) reported

that female residents come to the primary healthcare centers principally for the health

needs of their children.

Theme 2: Reliance of services on the skills of nurses/midwives. Primary

healthcare in Isu is provided and managed generally by nurses, midwives, and other

allied healthcare professionals (Participant 1) who are readily available. Participant 2

stated,

We do not have a permanent doctor here, which is why it is called a primary

healthcare center, though we have a visiting doctor who comes around on

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stipulated days or week. We have permanent doctors at secondary healthcare

centers.

Participant 3 explained, “We provide services to pregnant women seeking

deliveries [of their babies], do circumcision and immunization of children, treat upper-

respiratory-tract infections, and sometimes give tetanus injection to adults with cuts.”

Accessibility

Theme 3: Proximity of services. Six nurses and midwives (100%) and two

(67%) of the three healthcare administrators stated that the proximity of healthcare

centers to the community was adequate to meet the needs of the community and reduce

mortality. Participant 2 described primary healthcare as an obligation of the government

to the people, especially for those in the rural areas who may not be able to pay for

hospital treatment. When asked about proximity to healthcare centers and posts, four of

the six nurses/midwives (67%) and nine of the 12 residents (75%) revealed that proximity

to healthcare centers and posts to people have helped reduce incidence of such epidemics

as polio, whooping coughs, measles, and tetanus. “Services are primarily for infants and

children” reported participant 4, a nurse. Participant 5 stated, “It is essentially a

grassroots healthcare to reduce infant and maternal mortality rate for rural residents in

Isu.”

Accommodation and acceptability

Theme 4: Timing of services. The health centers operate a 3-shift schedule to

cover a 24-hour period each day to save lives, prevent disease, and promote better health

for local residents of Isu, especially for those who may have limited resources for seeking
 84

care from private doctors or for traveling to the hospital. All nurses/midwives (100%) and

residents (83%) agreed that keeping the health centers open all times was important for

the community.

Theme Cluster 2: Challenges and Barriers to the Primary Healthcare System

For Research Questions 1b and 2b, all respondents (including healthcare

administrators, providers, and residents) described the main challenges and barriers faced

by the local government healthcare system; 10 themes emerged from the responses:

Availability

Theme 5: Facilities are poorly maintained and lack essential amenities.

Residents (100%) and healthcare providers (80%) said that healthcare centers lacked

electricity, water, and sanitation supplies. Participant 1 reported that the primary health

center has no placenta pit or site for disposal of organic wastes. Participant 21 reported

that health centers are dirty, uncomfortable, or uninviting to patients. Participant 19

questioned, “How can a woman under labor begin to think about carrying water and/or

providing a lamp if labor begins in the middle of the night? If government wants to do

something, they should do it fine.” Participants described the environment of many health

centers as unattractive, poor, and badly kept. In addition, they reported that some health

centers need new floors, windows, beds, nets, and even seats suitable for public use.

Participant 20 lamented that some of the community health centers have no mosquito

netting and that newborns are exposed to bites if they are not properly covered.

Participant 4 explained how daunting it was to deliver babies in the middle of the

night with only kerosene lamps as a source of light and how inconvenient it is for new
 85

mothers to wait until water is brought to them from their homes before they can shower

after delivery. Participant 5, a healthcare provider, asked, “How can a healthcare center

function without power to refrigerate vaccines or water for proper sanitation during and

after delivery?” Participant 7 expressed concern that the health centers have no oxygen or

equipment to resuscitate patients and no incubators for premature babies. The participant

concluded, “It is God who is saving us most of the time.”

Theme 6: Lack of medical equipment. Four of the nurses/midwives (67%)

reported a lack of basic primary healthcare equipment that was both frustrating to them

and discouraging to residents who need care. Participants 3, 5, and 8 complained that the

government’s inability to provide healthcare centers with basic medical equipment and

supplies discouraged many residents from continuing to seek care at health centers.

Residents (Participants 18, 19, and 27) reported that healthcare facilities needed to have a

laboratory, x-ray equipment, labor rooms, beds, and netted windows. Participant 16 said

the centers lacked the equipment to examine pregnant women properly and that even

regular physical examinations are hardly done well: “My pregnant neighbor was

delivering at the center and lost lots of blood. There was not blood transfusion, no doctor,

and she nearly died, but God saved her.”

Participant 25 remarked, “New diseases are here with us and you cannot treat

them just by looking at the patient. They need lab to know what is really wrong before

giving medicine.” Participant 26 indicated that “it is dangerous and risky to rely on this

kind of blind treatment for cure of diseases.” Participants also reported that lack of

transportation such as ambulance services at the centers interferes with their ability to
 86

respond to emergency health situations. In addition, participants (2, 3, 5, 8) reported that

most health centers generally lacked some important obstetric equipment such a vacuum

extractor, forceps, sterile gloves, obstetric forceps, an obstetric table, and drugs essential

for deliveries). Participants 12, 26, and 27 reported that patients feel greatly disappointed

when the health centers do not have the essential drugs or equipment needed for their

care.

Some resident participants (58%) were quick to point out that some of the health

centers had no equipment to measure blood sugar or blood pressure. Participant 7

remarked, “Patients are becoming increasingly more demanding about their care and

procedures. A local woman would ask for x-ray, and laboratory, blood pressure

services—even when not necessary—and will be disappointed if such services are not

provided.”

Theme 7: Lack of an ambulance or other transportation. Lack of means of

transportation has posed a great handicap to the operation of the local primary health

system (Participants 1, 2, 7, 19, and 20) especially for reaching patients in emergency or

critical health conditions in a timely manner. Participants 2 and 9 acknowledged that lack

of transportation for the health centers and the residents pose a great handicap in their

ability to respond to residents’ health needs. Participant 9 added that the Isu Local

Government Area has no public transportation or taxi services and thus, responding to

emergencies is difficult even in simple cases that nurses and midwives can handle. Those

residents who have their own transportation are still hampered by security issues and bad

roads, especially when emergencies or labor occurs during the night (Participant 9).
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Another participant said that chartering a taxi in times of emergency is very expensive

even during the day; many residents are not able to pay for both transportation and health

costs simultaneously (Participant 18). To underscore the importance of transportation in

emergency situations, Participant 16 cited a specific case where the availability of

transportation would have saved the life of a pregnant woman:

A pregnant woman was bleeding at home. She was brought to the center in the

night on a bicycle with blood over the place. There was not ambulance or

transportation at the center to convey her to the hospital. Hours were wasted

before a van was got to convey her to the hospital. She died on the way to the

hospital.

Theme 8: Lack of a resident doctor. Participants 4 and 7, who are registered

nurses/midwives, remarked,

When patients come to the health center, they want to see a doctor and not a

midwife or nurse or CHEW because they believe that only a trained doctor will be

able give them a proper diagnoses for their diseases or sickness.

Another participant (27) added, “Nurses and midwives are no substitutes for trained

doctors!”

Participant 3 added that “the local health system has only nurses and midwives,

and CHEW, and many times residents are not satisfied seeing any of us for their cases.

They prefer to see a doctor.” Participant 18, complained,

How can I go to a health center with no doctor, and after waiting long to see a

nurse, get a prescription that is out-of-stock, and then have to go out looking for
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the drugs. It is better for me to go to a chemist [a drug store operated by local

drug seller in the village] or see a traditional healer if it is what they can handle

for me.

Participants 23 and 27 stated that they do not use primary healthcare centers because

there is no doctor on duty and because of the increased cases of fake drugs in circulation.

Because the primary healthcare centers do not have regular doctors on staff and

have little or no equipment, two participants (23 and 24) described the primary healthcare

service as trial-and-error practices. Nurses and midwives remarked that operating a

primary healthcare system without a doctor was hard for them, especially with emerging

health needs of the aging population and complications from child delivery. Participants

11 and 25 remarked that some of the catastrophic deaths that have resulted from child

birth could have been prevented if a doctor had been on duty during the emergency.

Most residents (83%) do not go to the healthcare centers for their personal health

problems because the healthcare centers do not offer services that meet adult health

needs. A participant (24) remarked that the health centers are staffed by nurses and

midwives, and extension workers whose skills are inadequate to meet their health needs

of adult members of the community. According to two participants (16 and 26),

healthcare centers do not offer reasonable services for adults in the community because

they lack the facilities and qualified staff to diagnose most adult problems.

Most of the residents (75%) perceived the experience and skills of

nurses/midwives and CHEWs to be limited and feared trusting some of their health

conditions to what they perceived to be trial-and-error practices. Participant 27 stated, “I

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cannot trust my healthcare to a nurse or midwives.” Pointing to swollen knees and hip,

Participant 27 described having suffered terribly from those problems because the

participant could not see a doctor or get proper medical help anywhere nearby.

Theme 9: A shortage of medical support staff to run the health center. Three

participants said that the primary healthcare center lacked support staff capable of

educating the public and creating awareness of the services it offers (3, 8, and 9).

Participant 16 remarked, “I do not go to anyone because I do not know what services they

offer.” Some participants complained that the healthcare system does not have staff to do

home visits, create awareness of their programs, or educate them on available services or

disease prevention (5, 21, and 18).

Resident and healthcare providers remarked that the local healthcare system has

no laboratory staff who can conduct basic tests (Participants 2, 3, 23, and 24), so nurses,

midwives, and CHEWs rely on guess work to diagnose and prescribe drugs (Participants

23 and 24). The high cost of care and personal attitude of some residents impacted their

ability to seek healthcare from primary healthcare facilities even when facilities were

nearby.

Accommodation

Theme 10: Lack of essential drugs. Most healthcare providers (Participants 4, 5,

6, 8, 9, 10, and 13) and residents (17, 19, and 24) stated that the local healthcare system

always has a shortage of essential drugs and healthcare supplies, which limits the ability

of the nurses and midwives to give the highest level of service to residents. Participant 19

said that health centers are always “out of stock with drugs.” Two participants (20 and
 90

26) complained that the health centers required them to buy drugs from outside vendors,

which exposed them to the potential of purchasing fake or adulterated drugs. Participant

19 told a story of a fake Ampicillin drug for children that contained baby food inside the

bottle instead of the true antibiotic medicine. Three (50%) of six female resident

participants confirmed this story, and reported that Ampicillin was commonly prescribed

for children, but was not available at health centers so residents were forced to buy the

drug from private patent-medicine stores. Participant 20 added, “Our children got sicker

with consuming non-potent fake drugs, and we wasted our money for nothing.”

Affordability

Theme 11: Excessive cost of care. With regard to excessive cost of care,

Participant 17 shared this story:

Mrs. [name withheld] delivered her baby in one of primary health centers. She has

been coming to this center for antenatal. When she delivered, she was told that her

baby had jaundice. The center did not have drugs and the nurse told her to bring

money for her to buy the medication. The woman had no money. After 3 days,

she was discharged to go home, though the nurse told her that her baby’s case was

serious. The woman went home and while the husband was trying to find money

to buy the drug, the baby died.

At the end of this narrative, all the women sighed in disappointment. One participant

said, “Does life not worth more than money? Why not treat her, save the baby, and she

will pay later?” Another participant (13) described services at the health centers as too

high for some patients and blamed that high cost for keeping some residents from seeking
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care from primary health centers when they are sick. Some residents who cannot afford

the cost of care are forced to adopt a “wait–and-see” attitude toward their health, hoping

the sickness will go away.

Another participant (26) added, “They may visit patent drug vendors, traditional

healers where they can negotiate the cost of care; or go to a prayer house.” Five residents

complained that the cost of care is high for some residents to pay. According to the

participants, some mothers were unable to pay for certain injections or medications for

their babies born sick and must go home and let the baby die a few days later. Contrary to

orthodox medical practice, traditional healers provide services that residents can afford at

all times. A participant (14) remarked, “No good medicine man or healer will prescribe

drugs (herbs) beyond the reaches of the patient.” The participants stated that providers of

the English type of healthcare discredit traditional healthcare due to their greed and fear

of competition. They described their relationship with the orthodox primary healthcare

system as unacceptable, discouraging, and biased.

Other Concepts

Theme 12: Poor and irregular pay. Several participants reported a lack of

professional development and compensation to deserving employees, resulting in low

employee morale and decreased productivity.

Healthcare providers, mainly nurses and midwives, reported that lack of regular

training and good reward system affected their attitude toward their work as well as their

ability to do their work. One participant (5) said, “Our salaries are small and besides, not

paid regularly.” Another participant (7) added, “Sometimes we are owed up to 3 months
 92

areas of salaries.” Participant 9 reported, “We hardly go to any training or workshops nor

do we receive any tuition reimbursement or bursary for advanced education.”

Theme 13: Unstable leadership and local government politicking. Several

participants spoke of the instability and selfish interests of local government leadership,

and their interference with the objectives and performance of primary healthcare delivery.

According to the majority of the 27 participants, frequent changes in leadership often

mean that the local chairs are unsure in their positions and thus lose focus and indulge in

practices to enrich themselves and their political forefathers. Two of the participants (2

and 3) reported that leadership of the local government does not involve health

administrators or providers in budgeting issues or allocation of funds for the health

department. Another participant (7) said that the primary healthcare department hardly

has a formidable plan, as every new leader comes with a different plan or no agenda at

all. A participant (22) also remarked that some national-level political leaders influence

decisions at the local government level, causing the leadership to undermine essential

community services, including primary healthcare. Residents felt that corruption among

those in authority resulted in mismanagement of healthcare funds and misplacement of

community priorities.

Theme 14: Healthcare professionals not involved in policy and budgetary

decisions. Two participants (2 and 9) reported that the local government chair is the

principal decision maker on healthcare and in many cases overrides the decisions of

healthcare professionals at local government headquarters. Participant 2 added, “I am

here as an obedient servant. I have not political clout and nobody listens when I
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complain. I do not want to lose my job.” Health administrators reported the absence of

collaboration and consultation between the health department and the local-government

leadership, which impacts the resolution of important healthcare issues and adversely

affects service delivery. Two of the participants (2 and 3) revealed that proper resource

allocation, budgeting, and health-center management are not practiced. One participant

(5) reported that some healthcare centers are geographically located based on locations

convenient to the government rather than being central to the general community. As a

result, some who oppose the particular powers in office at a particular time do not go to

the centers for care.

Theme Cluster 3: Solutions to the Challenges Faced by the Primary Healthcare

System

For Research Questions 1c and 2c, all respondents (including healthcare

administrators, providers, and residents) were asked about potential solutions to the

challenges reported above. Four themes emerged from the responses of all participants:

Availability

Theme 15: Provide a comprehensive primary healthcare system. Most

residents, nurses and midwives required that variety of qualified medical staff be

employed by the local healthcare system to provide comprehensive healthcare service.

For instance, Participant 9 said that healthcare cannot function well without doctors.

Another participant (6) said, “Our primary healthcare are not designed like hospitals and

cannot serve all needs unless nurses and midwives are given higher training and health

centers equipped properly.” Participant 15 said, “Our health centers should provide
 94

services such as the ones by hospitals in the British days that had good doctors and

medicine.” Another participant (11) added, “Those days, nurses see you first and then

send you to the doctor who will examine and write prescriptions.” Three of the

midwives/nurses (50%; 5, 8, and 9) suggested a free treatment for all children (0–59

months) would be one way of making healthcare accessible to children and those who

cannot afford the cost of care. In addition, 81.48% of all participants recommended free

or subsidized healthcare for those who are most in need and those who are unable to

afford the cost of care in the Local Government Area.

Another participant suggested that health centers be supplied with essential drugs

(Participant 17). Of the participants, 91.6% of residents and 77.7% of healthcare

administrators and nurses/midwives suggested that health centers should be supplied with

essential drugs to encourage community use.

Theme 16: The local primary healthcare system should employ medical

doctors. Eleven of the 12 residents (92%) said that they needed a healthcare center with a

doctor present. Participant 27 said, “Most of our health needs are not what nurses and

midwives can handle. We do not become pregnant, and we are not little children.”

Generally, residents perceived effective healthcare from the standpoint of efficiency and

effectiveness in meeting their needs rather than on the availability of physical

infrastructure or staff who lack skills to help them. Some participants believed that most

of their health needs are beyond the expertise and training of nurses and midwives at the

health centers. Many residents (83%) expressed that they needed a doctor-run healthcare
 95

system that would reduce the incidence of pregnancy-related deaths, heart attacks, stroke,

and other diseases such as typhoid fever and malaria.

Theme 17: Fund the health system, equip and maintain the facilities. For this

themes, 78% of healthcare administrators and nurses/midwives suggested that adequate

funds be allocated to the primary healthcare system. 83% of nurses and midwives

recommended better training and improved professional development for primary health

staff, and 91.6% of resident participants suggested the need for well maintained and well-

equipped health facilities. One nurse (Participant 6) concluded, “Our primary healthcare

should be supplied with trained staff, adequate drugs, and proper equipment and

maintained before it can function efficiently.”

Accessibility

Theme 18: Provide mobile clinics and ambulances to improve access and

respond to emergencies. Healthcare administrators, providers, and residents shared

similar opinions on the solutions to the challenges and barriers residents face in accessing

primary healthcare in Isu. Two participants (23 and 27) requested a mobile clinic to reach

out to those who are home bound and very old people who are in great pain with arthritis

and other age-related diseases. Participants 1, 2, 7, 19, and 20 suggested that the local

health system be provided with well-equipped ambulance services to respond to

emergencies and save lives.

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Theme Cluster 4: Relationships between Local Health System and Traditional

Healers

For Research Question 1d, healthcare administrators and providers were asked

their perceptions regarding the potential for closer relationships between the local-

government healthcare system and traditional healers. Three themes emerged from this

question:

Accessibility

Theme 19: Some orthodox health providers disregard traditional healing.

The primary health system considers traditional healing to be crude, unscientific, and

diabolic, thereby affecting some residents’ attitude to accessing traditional care when in

need. Three nurses/midwives (50%) and a healthcare administrator (33%) described

traditional healing practice as unscientific or crude. These three nurses/midwives

perceived care by traditional healers to be associated with a high risk of contamination or

cross infection. They recommended reducing risks associated with traditional healing

practice through proper education and regulation of practice by an approved government

agency. A participant (5) described some traditional healers as charlatans who complicate

issues and deceive clients with unnecessary rituals instead of giving them potent drugs or

herbs. Traditional healers had a different view about primary healthcare: 83% of

traditional healers were of the view that English medicine (primary healthcare) has lost a

genuine concern or passion for healing and patient care; instead it is interested in making

profit from consumers.

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Other Concepts

Theme 20: No professional relationship exists between traditional healers

and the primary healthcare system. Traditional healers are not officially involved in or

regarded as part of the local health system operated by the local government. Views

varied among different participants. Participant 2 said that traditional healers should be

permitted to provide services that the primary healthcare system does not offer, such as

bone setting for fractures and dislocations or care for snake and dog bites. Two

participants considered the involvement of traditional religion in healing as idolatry,

according to the predominant Christian belief in Isu. Two nurses and one healthcare

administrator decried the appearance and level of education of traditional healers as unfit

for an association as health-profession colleagues.

Three traditional healers (50%) think that greediness on the part of the orthodox

trained professionals is the key issue in isolation and disregard of traditional healing

practice. One participant (14) described government healthcare providers as being more

concerned with making money than with patients’ care and health service.

Traditional-healer participants (11 and 15) said that they are called by the spirits

of the ancestors to provide affordable services—not to be concerned with profit making

as is the practice in orthodox medical practice. Participant 11 indicated, “Government

primary healthcare systems look at money and not at the well-being of the patient. We,

traditional healers do not do so. We cure and you pay later! Ndu ka aku [life is worth far

more than wealth].” Participant 10 remarked, “Ogwu di ire, akota onye gworo ya [When

a healing is effective, people tell the story to others, and more business comes].”
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Participant 12 added, “We are here to heal and not to make profits as are the orthodox

healthcare providers.”

Theme 21: Traditional healers want recognition and legitimacy. In spite of the

services traditional healers render to complement the services of the primary healthcare

system, they are still struggling for integration and recognition by the local health system.

Participant 9 recommended that for traditional healers to be recognized and considered

part of the primary healthcare system, they “should be educated by the government on the

basic concepts of care for pregnant women and delivery of babies just like the traditional

birth attendants.” Participant 6 said, “Traditional healers should be allowed to treat

certain diseases such as typhoid fever, malaria, bone setting, and evil attack which they

are already known to cure.” Some healthcare administrators, nurses, and midwives

consider traditional healing to be fetishist and crude.

Participant 13, a traditional healer retorted

Religion has made many people believe that traditional healing is equal to idolatry

[worshipping of false/another god], so the use of traditional healing by people for

cure are sought in secret or mostly by those who are or do not care about their

Christian beliefs.

Another participant 15 queried, “Do we not believe in God? What about doctors who are

not Christians or do not go to church?” Participant 10 cautioned, “Religious groups

should not preach against the power or potency of herbs and our abilities to heal because

they are given to us by God.” Participants described traditional healing as a tradition that

cannot be separated from the people.

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Theme Cluster 5: Residents’ Confidence in the Healthcare System

Research Question 2d, residents were asked about their perceptions regarding

confidence in the local government healthcare system and in traditional healers. Four

themes emerged from the responses of the 12 respondents to this question:

Availability

Theme 22: Participants trusted traditional medicine because they found the

services affordable, available, and accessible. Participants 17, 23, and 26 reported that

response times by traditional healers are significantly better than response times by staff

at health centers, where one can wait hours for service. Participant 22 indicated that

“herbs do help me a lot and I trust their efficacy than consuming chalk [fake or

adulterated drugs] as medicines.” Participant 27 stated, “Traditional healers have a sense

of commitment and urgency to serve.” Other participants (14 and 15) who have used or

had experiences with those who have used traditional healers attested to the truth of this

statement. Another participant (14) remarked that traditional healers consider the ability

of the patients in figuring charges for their drugs. According to the participant, “You can

always negotiate the price you want to pay or pay by installments.”

Some women participants (33%) had no confidence in traditional healing due to

their religious beliefs or dislike for the appearance of the healers. In the same

condemnation, a participant (21) expressed that, “Going to a “dibia” [meaning traditional

healers] is against my religious belief.”

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Accommodation

Theme 23: Healthcare-provider attitudes impacted residents’ healthcare

use. Some resident participants (50%) complained of a poor attitude of some healthcare

employees, citing examples such as tardiness to work, leaving early, rudeness, delays,

and a lack of a sense of urgency. Participant 21 complained, “It takes forever to get your

card when you there. You have to beg them some of the time.” Another participant (20)

added, “Sometimes you have to pay for another card and there is not follow up with your

previous case or sickness.” Participant 20 shared a story:

I took my sick child to the clinic and the baby was crying uncontrollably. As I

reached the clinic, the baby was still crying and I beckoned on the nurse to take

the baby from me. I said, nurse take this child from me, take this child from me. I

begged and nobody listened. I took my child outside to avoid disturbing others. I

was sad and disappointed on how I could be so neglected with my sick baby. My

child cried agonizingly until I was called to see the nurse. … Some of the nurses

have their hearts at the back [are heartless].

Two resident participants (17 and 20) cited that they go to a particular healthcare center

because of the good attitude of the staff there.

Acceptability

Theme 24: Some participants were confident in primary healthcare services.

Some participants trust primary healthcare to the extent that it met their needs during

pregnancy and the immunization of their children. Two female residents (33%) of six

female residents only expressed satisfaction with and confidence in the services of the
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local primary healthcare system. One participant (17) said she received adequate care

during pregnancy and delivery, whereas another (Participant 20) said she had all her

children immunized at the health centers. One participant (17) expressed full confidence

in the primary healthcare system and indicated that her satisfaction came from being able

to get appropriate care during her two pregnancies and ongoing healthcare for her two

children.

Theme 25: Some participants were not confident in primary healthcare

services. Reasons that influenced participants’ confidence in the primary healthcare

systems depended on the extent to which it met their individual needs or those of

members of their families. All six male participants (100%) had no confidence in the

primary healthcare system because it did not provide any services that met their needs.

Participants 23 and 27 stated that they do not use the primary healthcare centers because

of the increased cases of fake drugs in circulation. According to them, “primary

healthcare give English medicines which has many imitations in the market today.”

Another two participants (24 and 26) described the services at the primary healthcare

centers as “trial and error” because of the absence of resident doctors at the centers.

Participant 20 trusts the capabilities of the healthcare centers, but not when cases become

complex or require urgent attention. When asked why, Participant 20 indicated that the

lack of equipment and no doctor at the centers was very discouraging and disturbing

because they would not be prepared to take care of the participant if complications arose

during delivery. Similarly, Participant 19 indicated that willingness only to go to health

centers with very minor health issues.

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Theme Cluster 6: Role of Community-Based Research in Primary Healthcare

For Research Question 3, all respondents (including healthcare administrators,

providers, and residents) were asked about their perceptions regarding community-based

research as a means of promoting the use of healthcare services among the rural residents

of Isu.

Community-Based Research

Response from all the respondents resulted in the following two themes:

Theme 26: Participants want to be involved in community-based research.

The majority of participants (81.48%) welcomed the idea of community-based research.

Other participants (18.5%) were concerned about whether local primary health leadership

would actually value and use their input to improve healthcare delivery. Of residents,

83.3% expressed willingness to participate in community research if contacted on time.

Two participants (7 and 25) recommended that some type of reward be given to

encourage people to participate in the research. Four (66.6%) of six traditional healers

indicated interest in participating at any time called to do so.

Theme 27: Community-based research improves resident access to primary

health care. Most participants were receptive of community-based research and

considered it an innovative approach to improve resident access to primary health care.

Generally, 93% of all participants—health administrators, healthcare providers, and

residents—perceived community-based research to be an innovative path to a better local

healthcare system. Healthcare administrators and midwives/nurses (2, 3, 8, and 9) agreed

that a community-based research approach to healthcare can help nurses and midwives
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share their opinions about their challenges and strengths, as well as the feedback they

receive from residents, which in turn will provide the primary healthcare system with an

opportunity to improve healthcare delivery for residents. Participant 3 (a healthcare

administrator) said, “Residents will tell us what they like or dislike about us, our services,

and whole healthcare system. In this way we can do better.” Participant 8

(nurse/midwife) stated that “community healthcare is community owned, so it makes

sense to interact with them from time to time, including hearing their opinions about us

who are giving the healthcare.”

Participant 16 (resident) added, “Involving us will be a good idea, but the

government is greedy and would not like us to know what they are doing.” Traditional

healers (Participant 14) remarked that community-based research was innovative, but

questioned whether orthodox healthcare providers would afford them due respect with

regard to their opinions.

Summary of Results

Grouped by theme, the results of this study provide insight about the research

questions posed for this study. Specifically, the results of this study provide insight into

the experiences of the residents of Isu about their access to healthcare services as well as

their expectations of primary healthcare services. Results from this study also provide

insight into some of the difficulties and challenges of providing effective healthcare

services that affect the use of primary healthcare services in the Local Government Area

as well as possible solutions to these problems.

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Results indicated that the characteristics of the current healthcare system can only

support maternal and childcare rather than addressing the communities’ desire for

comprehensive care (Theme Cluster 1: RQ 1a and 2a). The inability of the local health

system to offer comprehensive care is inherent in the many challenges and barriers facing

it, ranging from no doctor on site, and a shortage of drugs, to poor funding and

inadequate maintenance and equipment of the healthcare facilities (Theme Cluster 2,

Research Questions 1b and 2b). Various participants’ responses suggested some possible

solutions to the problems, such as having doctors and drugs on site and providing free

and subsidized healthcare; these factors would improve their access to healthcare (Theme

Cluster 3, Research Question 1c and 2c). Considering the complementary role of

traditional healers, participants feel that they should be recognized to offer specific

services, but need some training to avoid cross contamination in care (Theme Cluster 4,

Research Question 1d).

Services of traditional healers are still patronized by residents despite the lack of

recognition by the local healthcare system. Services of traditional healers are still

valuable to residents as they continue to patronize them due to their affordability and

accessibility in time of need in certain cases (Theme Cluster 5, Research Question 2d).

The community-based research approach used in this study received strong support from

participants (Theme Cluster 6, Research Question 3).

The overall results of this study show how committed community members were

to issues of their health and the desire for change. The research results presented above

focused on the characteristics of the healthcare system that impact healthcare access;
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barriers and challenges affecting the healthcare and possible solutions; traditional healers

in the healthcare process; and the value of community-based research in improving

community access to healthcare.

Discussion of the results of this study, described under the specific Theme

Clusters, is presented in Chapter 5.

Evidence of Quality

According to Trochim and Donnelly (2008), evidence of quality in a qualitative

study is best described in terms of credibility, transferability, dependability, and

conformability, and how well the results of a study approximate the truth. Because I

conducted qualitative research, I judged the quality of my study results using these

concepts as applicable to my study. Evidence exists that my study results are confirmable

and credible and, therefore, approximate the truth with regard to healthcare

administrators and residents’ perspectives about residents’ access to healthcare and the

potential for community-based research to serve as a means of promoting the use of

healthcare services.

One piece of evidence indicating confirmability of my results is that the second

coder identified themes similar to those I identified. For example, both the second coder

and I identified proximity of services, timing of services, effectiveness of services,

inadequate medical equipment, shortage of essential drugs, lack of a resident doctor, and

high cost of care (see Appendix W).

One piece of evidence indicating both credibility and confirmability of my results

is that the participants had few corrections to make to my debriefing/member-checking

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notes. One healthcare administrator suggested I clarify that although doctors tend to be a

priority at the secondary-care level than at the primary level, it does not mean that

primary healthcare centers should not have a doctor. One nurse suggested I add

mandatory professional development for nurses and midwives to acquire new clinical

skills annually, funded by the local government. Another midwife asked that I clarify

what I mean by “midwives and nurses are not substitutes for doctors,” thinking that I was

undermining their role in the primary healthcare system. One traditional healer clarified

that they actually are not asking to compete with orthodox healthcare, but be allowed to

perform their own services without unnecessary antagonism from orthodox healthcare

practitioners. No residents made suggestions with regard to my interpretations of the

data; however, they urged that the results be made available to the government to

encourage government to improve their healthcare.

Another example of credibility in my study is the result of my prolonged

engagement with participants. By spending time with participants, I was able to build a

rapport with them and earn their trust so they shared intimate experiences with me. For

example, one participant described begging nurses at a clinic for help for her sick child

who was crying in agony and the discouragement the woman felt about the heartless

treatment. The sharing of such private and personally painful experiences suggests that

participants trusted me and shared truthful experiences.

Another example of credibility in my study is the result of the triangulation of

data. The data I collected from the four different groups of participants using two

different data-collection instruments were similar among the groups. That the four groups
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generally agreed on the conditions associated with healthcare access for residents in Isu

suggests that the data I collected were valid.

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Chapter 5: Discussion, Conclusions, and Recommendations

The purpose of this case study was to explore the perceptions of rural community

residents and healthcare providers (government healthcare administrators including local

government chairs and senior healthcare administrators, nurses and midwives, and

traditional healers) regarding residents’ access to primary healthcare services in Isu, and

to examine the benefit of using community-based research to promote resident use of

those healthcare services. Despite the presence of local healthcare service in the

community, many people still die from preventable causes. As a result, it becomes

expedient to explore the opinions of healthcare providers and residents on the reasons for

and against their use of local primary healthcare services. A total of 27 participants were

interviewed to collect data for this study. Isu Local Government Area was chosen for this

study because it possessed the characteristic of a rural community with limited access to

essential amenities including healthcare (Adeyemo, 2005; Hudec et al., 2006; Umebau,

2008).

To gather various perspectives on the topic, I used two data-collection methods

(interviews and focus groups) and four data-collection instruments. To analyze my data, I

used Colaizzi’s (1978) seven-step method for coding data. This method provided a

rigorous tool to analyze human experience in real life and in the environment where a

problem exists to explore health access issues in Isu. The main foci of the study were

(a) how the healthcare system currently functions, (b) residents’ use and perceptions of

available healthcare services, (c) the effectiveness of available healthcare services,

(d) solutions to overcome identified challenges and barriers to healthcare implementation,

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(e) the role of traditional healers in the healthcare process, and (f) the value of

community-based research. Results from this study, as shown in Chapter 4, are briefly

summarized below. Chapter 5 interprets the key findings from this study as they relate to

the specific themes in Chapter 4 and concludes with a summary of results, limitations,

and recommendations for further study. I explain the interpretation under the specific

theme clusters.

Summary of Key Findings

The following key results emerged from the study:

• Although healthcare centers are located in every community in the Local

Government Area, the primary healthcare system is mostly focused on

maternal health and child healthcare. (Theme Cluster 1: RQ 1a and 2a).

• The local primary healthcare system is faced with many challenges such as

shortages of health providers (doctors in particular), drugs, and supplies; lack

of basic equipment and facility amenities; poor facility maintenance; and

inadequate funding. (Theme Cluster 2: RQ 1b and 2b).

• Political instability and poor leadership at the local government level has

greatly interfered with the performance of the primary healthcare system and

kept it from achieving its healthcare objectives. (Theme Cluster 3: RQ 1b and

2b).

• Participants’ proposed that having doctors and drugs on site, and providing

free and subsidized healthcare, among many others solutions, would improve

their access to healthcare (Theme Cluster 3: RQ 1c and 2c).

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• Traditional healers should be recognized and certified to treat certain diseases

in which they have expertise and also be trained to improve their skills to

reduce cross contamination in practice. (Theme Cluster 4 RQ 1d).

• Α poor healthcare provider work ethic and attitude hampers residents’ access

to primary healthcare services. (Theme Cluster 5: RQ 2d).

• Residents still trust and use traditional healers because of the acceptability,

availability, accessibility, and affordability of their services. (Theme Cluster

5: RQ 2d).

• Participants perceive community-based research as innovative and a valuable

source of feedback for the local health system to improve access to primary

healthcare for the residents of Isu. (Theme Cluster 6: RQ 3).

Interpretation of Findings

In this subsection, I discuss my interpretation of the findings presented in Chapter

4. The categories are elements of the primary healthcare system that work well (Research

Questions 1a and 2a), barriers to the successful implementation of the primary healthcare

system (Research Questions 1b and 2b), solutions to the challenges faced by the primary

healthcare system (Research Question 1c and 2c), relationships between the healthcare

system and traditional healers (Research Question 1d), residents’ confidence level in the

primary healthcare system (Research Question 2d), , and the potential role of community-

based research about the primary healthcare system (Research Question 3).
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Elements of the Primary Healthcare System that Work Well (Research Questions 1a

and 2a)

The basic elements of the primary health system that work well were proximity to

healthcare services, a 24-hour operation schedule, availability of nurses and midwives,

and efficiency of services to women in labor and child health.

The local healthcare system maintains health facilities or posts in every

community, including a primary healthcare center at local-government headquarters.

Proximity of the healthcare facilities to residents was important to improving access to

immunization of children and providing services to some women in labor (Federal

Ministry of Health & National Primary Health Care Development Agency, 2009). The

health facilities are managed by registered midwives/nurses and CHEWs to provide basic

maternal and child healthcare services. CHEWs treat minor illnesses and provide health

education and promotion services to the community. Studies show that patients who are

exposed to health literacy are in a better position to manage their health than those who

lack it (McMurray, 2007).

The operation of primary healthcare in Isu revolved around the skills of

nurses/midwives and CHEWs. This was so because of the shortage of medical doctors

and their preference to work in urban areas rather than rural areas. Nurse/midwives and

the CHEW workforce are the most available health labor force willing to work in rural

areas and thus have become the focal beacon of the local healthcare labor supply (Ladipo,

2009). Though some residents were pleased with the role of midwives and nurses in baby

deliveries and care, many also regarded the absence of doctors as a serious deficiency in
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the system. The use of an hourly contracted medical doctor did not work well because

doctors have private clinics and were not available, even on scheduled days; residents

expected a doctor-run health system with nurses, midwives, and CHEWs providing

support services. Residents have long associated midwives with the running of maternity

homes located in communities, where they perform deliveries and circumcisions, provide

ante- and postnatal maternity care, and treat simple wounds—but do not function as

doctors. Nurses, in contrast, are known for working in hospitals with doctors rather than

alone, and performing expected duties at healthcare centers. Essentially, nurses’ jobs are

to promote health, educate the community on disease prevention, and help patients cope

with illness, whereas doctors are trained to diagnose and treat illnesses in patients

(American College of Rheumatology, 2012; U.S. Bureau of Labor Statistics, 2012). Also,

CHEWs generally are known for providing health education, doing home visits, and

sometimes giving vaccinations. Men and women have different health needs as they age

(WHO, 2012), and those needs will not be met by nurses, midwives, and CHEWs

operating the local healthcare system. A doctor’s care cannot be substituted in that way.

Residents were more critical of the lack in the basic characteristics of the

healthcare system than were health administrators, nurses, and midwives, who were

interested in protecting their jobs. Traditional healers clearly see the problem with the

nature of the current healthcare system structure but also have no power to make any

changes—or even to make simple suggestions.

Though the local health system has endeavored to improve “access” by bringing

healthcare facilities closer to the people, it struggles to meet the goals of National Health
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Policy, which is to bring about a comprehensive healthcare system, based on primary

health care that is promotive, protective, preventive, restorative, and rehabilitative to all

citizens within the available resources, so that individuals and communities are assured of

productivity, social well-being and the enjoyment of living (Abdulraheem, Olapipo, &

Amodu, 2012; Adeyemo, 2005). The local health system is also deficient in defining

characteristics of primary health care, as defined by the Declaration of Alma-Ata

(International Conference on Primary Health Care, 1978): focusing on essential health,

accessibility to all individuals and communities, sustainability and reliability, community

participation, equity, and a sound scientific base. Health is a fundamental human right,

and the characteristics of the local primary healthcare system greatly impact the ability of

rural residents to access healthcare equitably and efficiently (International Conference on

Primary Health Care, 1978). In contrast, the primary healthcare system does not offer

services that meet all needs of individuals and families in the community, nor are the

services universally accessible.

The operation and functionality of the local healthcare system is confusing and

inadequate: operated by nurses, midwives, and CHEWs, it provides basic maternal and

child health services and basic first aid. This situation has prompted residents and some

providers to ask, “What actually is primary healthcare?” if it cannot provide services that

meet community needs. This question asks to know if healthcare-system administrators

really understand the healthcare needs of the community and what the health system

should be doing. Residents’ views demand that the services and operation of a primary

health system emanate from economic, political, and sociocultural conditions common to
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the community it serves, as indicated in the Declaration of Alma-Ata (International

Conference on Primary Health Care, 1978). It is the expectation of residents that an ideal

primary healthcare system should be functionally efficient and effective at all times and

have the capability to attend to their primary health needs. Contrary to this expectation,

some healthcare administrators and providers understood access to primary healthcare in

the context of location, whereas residents understood primary healthcare in the context of

functionality—that is the ability of the primary healthcare facility to meet every

residents’ healthcare needs, irrespective of age, gender, or socioeconomic status. This

conceptual controversy seemed to have influenced the perceptions of healthcare providers

about the type of services they offered people.

In the opinions of residents and some healthcare providers, running a primary

healthcare facility without a doctor is risky and has affected most residents’ attitude about

seeking care from local health centers. Using all-female staff as providers was not

welcome to some men who felt certain issues were too private to discuss with a female

provider. Having all female providers was not acceptable to certain demographics of the

community either (Liu & Dubinsky, 2000). The primary healthcare workforce is

dominated by women and lacks diversity. The nature of nursing and midwifery

professionals in Nigeria attracts more women than men, and as a result, the chances of

facilities being staffed with male nurse/midwife providers in the local healthcare system

are low. Workforce diversity in the healthcare setting is seen as a means of providing

relevant and effective services (Anderson, Scrimshaw, Fullilove, Fielding, & Normand,

2003, p. 73).
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As nations look into the future of global healthcare access, it is essential that

healthcare planners, providers, administrators, and stakeholders look into the new

expectations from the viewpoint of the healthcare system. Little can be achieved if the

current characteristics of healthcare systems do not respond to changing times. Studies

have pointed to basic attributes that a healthcare system must possess to be effective and

provide equity of care. For instance, according to The Regenstrief Center for Healthcare

Engineering (2006), healthcare systems should conform to the following qualities:

1. Safety: healthcare should be safe and not cause injury to the patients.

2. Effectiveness: providing services based on scientific knowledge.

3. Patient-centeredness: sensitive to patients’ values and health needs, as well as

opinions.

4. Timeliness: prompt service, avoiding unnecessary delays in providing service

to clients.

5. Efficiency: avoiding waste in equipment and in supplies.

6. Equitability: providing care that meets all needs irrespective of gender or

socioeconomic factors. (pp. 4–5)

In view of these attributes, the local healthcare system in Isu still struggles, operationally

and organizationally, to meet the criteria of the primary healthcare system that

communities and some healthcare providers expected.

Considering the current situation in the local healthcare system, it may be more

acceptable to residents to have fewer healthcare centers that are well-run, well-staffed,

and well-equipped than to have several that are poorly maintained and badly run, without
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drugs and equipment. Administrators’ ideas of a functional primary healthcare system is

political rather than operational, a condition expressed in Penchansky and Thomas’s

model of healthcare access (1981, p. 127). This kind of thinking may have accounted for

the development of a healthcare system that lacks the necessary attributes necessary to

support the rural health care and health education needs indicated by the residents. This

fundamental difference can be resolved by adhering to the three accountability

relationships of (a) voice (between citizens/clients and politicians/policy makers),

(b) compact (between policy makers and providers), and (c) client (between providers

and clients (World Bank, 2004b).

Barriers to the Successful Implementation of the Primary Healthcare System

(Research Questions 1b and 2b)

Primary healthcare delivery in Isu is faced with numerous challenges (Themes 5-

14). The similarity in the concerns perceived by the different groups of participants

indicated that the local healthcare system has obvious performance concerns. Central to

the challenges was the human factor in the provision of healthcare services; this is the

greatest challenge facing the primary healthcare system (Theme 13). Poor leadership and

corruption, in particular, appear to be principal concerns. Many residents cited that

unhealthy politics has led to bad leadership at the local government level as well as

across the whole Nigerian government system, denying them the opportunity to elect

people who will care for them. Many residents and some health administrators clearly

expressed that services for local residents were not being provided as a result

governmental impositions. According to the literature, poor leadership and political

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instability have been responsible for the unsuccessful implementation of many

government policies and programs on healthcare delivery (Abdulraheem et al., 2012,

p. 13). Instead of working for the general good, local government leadership is pressured

to serve the interests of their benefactors to the detriment of the needs of the general

public. With corruption in leadership, public accountability has no place, but contributes

significantly to the failure of the local government primary healthcare system. Healthcare

administrators who run the system and residents who depend on the system for care

found this situation to be frustrating. Issues such as poor funding, lack of facility

maintenance, and poor equipping of facilities stemmed from poor leadership at the local

government level (Themes 5, 6, 7, 10, and 12). Isu Local government gets a monthly

allocation from the Federal Government to funds its operation including primary

healthcare, but the underlying issues associated with poor or lack of funding of the PHC

system is beyond the scope of this study and warrants a further study.

The intended benefit of locating healthcare centers in every village is being

thwarted by the inability of the local healthcare system to embrace a team spirit and

create a vision to identify and solve problems and challenges affecting the system. Some

of the problems were beyond the control of professional healthcare administrators and

healthcare providers in the Local Government Area. Oftentimes, these administrators and

healthcare providers have no input in funding or allocation of resources. According to the

literature, lack of agreement about organizational missions and politicized decision

making often underlie difficulties affecting the vigilance of public healthcare functions,

affecting public health functions (Novick, Morrow, & Mays, 2008, p. 38). Political
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instability and corruption resulted in the following barriers to the local healthcare system

in Isu: (a) inadequate funding of healthcare facilities—funds meant for healthcare are

diverted to other interests, (b) poor employee morale resulting in poor healthcare-worker

attitude, (c) ill-equipped and poorly maintained health centers, (d) failure to provide

doctors at health centers (Fan & Habibov, 2009; Onwejekwe et al., 2010), (e) lack of

essential drugs including vaccines (Ridde, 2011; World Bank, 2004a), (f) lack of

community involvement (Rust & Cooper, 2007; Wallerstein & Duran, 2006), (g) no

accountability, and (i) excessive cost of care (Abdulraheem, 2007; Hausmann-Muela,

Ribera, & Nyamongo, 2003). In a study of primary healthcare services in Nigeria,

Abdulraheem et al. (2012) found that primary healthcare facilities are in various stages of

disrepair, with equipment and infrastructure being absent or obsolete, and the referral

system almost nonexistent (p. 5). All these factors are signs of a failing healthcare system

(World Bank, 2004b).

Participants’ concerns about the condition of primary healthcare in Isu do not

appear to be ones that can be resolved without a change in the status quo. To transform

the system, there must be a shift in the current paradigm of leadership from political

leadership to community leadership by health professionals who are not under the control

of the local-government leadership system. Only strong leaders can enact change in the

healthcare system. Primary healthcare leadership must possess the “depth and breadth of

leadership skills that are responsive to health needs, appropriate in the social and

regulatory context, and visionary in balancing both workforce and client needs”

(McMurray, 2007, p. 1). The current arrangement, if it continues, will not foster change,
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and thus morbidity and mortality rates will not be reduced, and improved access to

healthcare for rural residents will not be realized. Transformation requires that leaders

engage in systemic thinking by looking into the current situations or demands for primary

healthcare services in order to make future plans (Novick et al., 2008).

Solutions to the Challenges Faced by the Primary Healthcare System (Research

Question 1c and 2c)

To improve access to primary healthcare, data suggested the changes are

necessary to improve primary healthcare delivery in the Local Government Area. To

improve access to healthcare and quality of services provided, participants recommended

the following:

• Establish a mobile clinical unit and ambulance services;

• Employ doctors at all healthcare facilities to properly diagnose illness,

prescribe medications, and oversee the work of nurses, midwives, and other

healthcare workers;

• Provide all health facilities with necessary tools and equipment, and maintain

them;

• Provide a regular supply of drugs and medical supplies;

• Provide professional development for healthcare staff and improved pay; and

• Provide free healthcare for all children 0–59 months, and subsidized care for

those who cannot afford to pay for healthcare services.

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The perspectives of residents mirrored those of healthcare providers and administrators

and both groups of participants acknowledged that the challenges translate into poor

quality of service for residents.

Residents and healthcare providers emphasized the importance of regular staff

training and professional development to prepare them for their responsibilities.

Residents, in particular, indicated that healthcare staff should be trained in better

customer service and human relations, as these are equally part of health care. Training,

as Abdulraheem et al. (2012) suggested, can enhance employees’ knowledge base and

equip them with modern skills and concepts in primary healthcare delivery as they relate

to rural communities. Also, participants preferred having fewer well-equipped and

managed facilities with a regular doctor to severely scattered, ill-equipped health

facilities throughout the community.

In addition, residents want mobile clinics to reach out to those who are home

bound and provide more extension workers who can conduct home visits and create

awareness of the services offered by the local health system. Mobile clinics have been

shown to be cost -effective in preventing chronic disease, controlling healthcare costs,

and reducing health disparities in underserved or remote communities (Hill et al., 2012;

Oriol et al., 2009).

Popular participant opinions suggested that an initial step in the solution process

lies in having leadership that is accountable to the people. Simply, there is lack of

accountability in public service in Nigeria, a situation that also affects the operation of

the primary healthcare system in Isu (Khemani, 2006). Part of the reason may stem from
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an unclear definition of the extent and limits of responsibilities shared between state

health ministries, ministries of local government, and local government councils

(Khemani, 2006, p. 5). This accountability is derived from sharing power between

providers and customers, and increasing community involvement in planning and

monitoring healthcare services (World Bank, 2010).

Local government leadership must take responsibility for the effective operation

of primary healthcare at the local government level. Data from this study indicated that

problems of access to healthcare can be minimized if there is leadership that ensures

(a) services are provided as expected, (b) adequate funds are allocated to provide

services, (c) proper services are provided according to identified needs, and (d) good

performance is rewarded and inappropriate behavior that leads to poor outcomes is

punished. When leaders begin to think in these directions, it may be possible to have

(a) improved provider–community communication and understanding, (b) maintained

and well-equipped health facilities, (c) a well-funded health system with staff to meet

areas of most need, and (d) comprehensive healthcare that considers the socioeconomic

needs of the community.

Closer Relationships with Traditional Healers (Research Question 1d)

Result shows that the local primary health system does not relate well with the

traditional healer. Traditional healers are generally not recognized in the orthodox

healthcare system as colleagues or primary healthcare providers. Findings indicated that

the local healthcare system still perceives traditional healers as indulging in crude and

unscientific practices. Prejudice exists between providers of orthodox medical healthcare

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and providers of traditional healing care (Theme 19). Residents still use traditional health

providers. In spite of the global call for integration of traditional medicine and

practitioners in the primary health system to reduce cost and minimize physician

shortages, the local healthcare system has not explored the potential for integrating

traditional healers into the local healthcare system. Traditional medicine and healers

provide cost-effective local resources and knowledge for disease prevention and

treatment (Bodeker, Carter, Burford, & Dvorak-Little, 2006). Bodeker et al. (2006)

showed that traditional medical care and therapies have been used extensively in the

United States, South Africa, India, and Australia.

Many Africans continue to use traditional medicine provided by traditional

healers because traditional medicines are effective and holistic in nature (Ityavyar, 1987;

WHO, 2007). The fact that traditional medicine and healers continue to play a significant

role in African culture and concept of disease and cure, it has been relevant to pursue an

approach to review the role of traditional medicine in primary healthcare and embrace its

successful services. The problems seem to be that orthodox primary healthcare providers

have not devoted time to study the role of traditional healers and the impact of traditional

medicine in primary healthcare. Also, there is still attachment to a colonial mentality that

anything traditional is unscientific, crude, and diabolic. Traditional healing care has some

inexplicable phenomena that cannot be explained scientifically. Africans are bound to

their culture, and traditional healing and medicine are inseparable parts of it. Perhaps the

best place for the local government to begin is with a clear understanding of traditional

medicine. Traditional medicine incorporates many of the long-held beliefs and customs
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that are specific to the culture of the people. It is on this basis that traditional medicine is

used to treat and cure various ailments in society as a complement to orthodox medical

practices (WHO, 2007).

The current negative orthodox healthcare-system view of traditional medical

practice is based on a long history of bias toward traditional medicine stemming from the

practice’s attachment to traditional religion (Ityavyar, 1987). Because some residents

have continued to use traditional healers irrespective of the continued wave of

antagonism and discredit by the Western medical system in Nigeria, healthcare policy

makers need examine how best to use local healer potential to extend primary healthcare

to rural residents.

Working toward understanding and accepting the role of traditional healers’ may

result in a shift of the relational paradigm between the local-government healthcare

system and traditional healers, from one of condemnation to one of consideration. An

established working cooperation between the orthodox healthcare system and the

traditional-healing system would encourage mutual communication, which could provide

a method to share medical knowledge and improve services offered by traditional healers.

A close relationship with traditional healers also affords the opportunity for traditional

healers to gain some understanding of modern medicine, and thus to help in disease

prevention for conditions such as HIV/AIDS. A closer relationship with training in

preventive and comprehensive healthcare will help them “gain prestige in their local

communities and respectability in the broader society by having links with modern

medicine” (Green, 2004, para 7). A closer relationship will turn antagonism into
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friendship, bring mutual cooperation, and encourage exchange and transfer of knowledge

among orthodox healthcare providers and traditional healers. This situation will improve

community access to healthcare and promote good health by reducing mortality and

morbidity (Cohen et al., 2007; International Conference on Primary Health Care, 1978;

Irwin et al., 2006). Rural communities can enjoy good access to healthcare if traditional

healers are engaged to complement orthodox healthcare services and to minimize issues

associated with the shortage of trained medical doctors in rural areas.

Residents’ Confidence Level in the Primary Healthcare System and Traditional

Healing (Research Question 2d)

Results of residents responses indicated that confidence level in the use of

traditional healers and the local health system varied. Many factors can affect the

confidence level of patients in a system. Among the factors contributing to the loss of

confidence was fear that they would not be treated well because of low staff skill level,

misdiagnoses, or unprofessional behavior from some health staff. Patients will often lose

confidence in a healthcare or provider whose skills or expertise are short of patients’

needs (Vadlamudi, Adams, Hogan, Wu, & Wahid, 2007).

With regard to the primary healthcare system, residents’ confidence levels rose

mostly due to the services provided efficiently by healthcare staff. Patients usually chose

a health system they believe has the capability to diagnose, treat, and care for them well

(Rudzik, 2003). Confidence in the healthcare system is associated with the satisfaction

patients get from using a healthcare facility.

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The reliance of the Isu local primary healthcare system on the competencies and

experiences of nurses/midwives, however, was a major reason for the loss of confidence

in the system among many residents. This was caused by the inability of the system to

handle life-threatening and emergency medical conditions, resulting in catastrophic

outcomes for the community. According to Rudzik (2003), “Patients become unwilling to

spend time and energy if they lack confidence in the system, which can lead indirectly to

serious health consequences” (p. 249). This system failing supports the reason older

residents do not use healthcare system services for their personal care and thus suffer

untold medical conditions from undiagnosed and untreated high-blood pressure, diabetes,

chronic pulmonary conditions, arthritis, and heart diseases (Amella, 2004; National

Academy on an Aging Society, 1999).

Though some people have little confidence in the local health system, others have

confidence in traditional healers and in the local healthcare system. According to Dr.

Welile Shasha, WHO country representative for South Africa, “Generally, confidence in

both traditional healing and the Orthodox primary healthcare system comes from the fact

that both services complement one another in the communities.” (WHO, 2004, p. 1).

Furthermore, Dr. Shasha added that studies have shown 80% of Africans depend on

African traditional medicine because it is their cultural heritage, and it is accessible and

affordable in times of need.

People in Isu still live in their natural traditional setting, see traditional healers,

and hear about them. As a result, most residents are familiar with traditional healers, their

reputations in treating diseases such malaria, fibroid, madness, and convulsion with
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herbs, and their service are within reach. Ascribing to confidence the reason residents

seek care from traditional healers, Green (2004) wrote, “Traditional healers are found

everywhere, unlike doctors who tend to work primarily in the larger towns and cities.

Healers are culturally acceptable; they explain illness and misfortune in terms that are

familiar, that are part of local belief systems” (p. 1).

This accessibility underscores the reasons and need for the services of traditional

healers in communities where patient–doctor ratio is high. The role of traditional healers

is in primary healthcare delivery and is receiving great attention worldwide. Traditional

healers have been shown to play a crucial role in public health and were identified as

“crucial nodes in any planned interventions for controlling the spread of HIV/AIDS” in a

study in Zimbabwe (Simmons, 2011, p. 477).

This notwithstanding, opinions are split on the levels of confidence in both

services. Lower levels of confidence in traditional healers or use of traditional medicine

were not based on the efficacy of drugs or effectiveness of traditional healers, but on

strict religious beliefs. The high level of confidence in traditional healers and services

were from participants who have patronized them for specific reasons and found them

better for the treatment of their medical conditions. Christian religious beliefs have

played a role in downplaying the importance of traditional medicine, causing some

residents to reject the practice as inauthentic medicine. Such concepts were crafted by

colonialists and quickly accepted by the indigenous orthodox medical practitioners in the

area (Ityavyar, 1987).

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Generally, the current level of service and operation of the primary healthcare

system in Isu does not give the residents any hope to sustain them in time of sickness.

The myriad of problems found in this study affected the effectiveness of healthcare

centers and the capacity of health staff to provide needed services. In addition, with more

maternal and child healthcare services offered than anything else, those who are not

served by these services, such as men and women over childbearing age, lost confidence

in the system. This condition reflects Penchansky and Thomas’s (1981) concept of

healthcare organization and how organization of services affects people’s perceptions of

those services and often results in a loss of confidence. The primary healthcare system

does not accommodate the needs of the growing aging population, and as a result,

discriminates in its care to the community. Most residents in rural communities are poor

and have limited or no income. Not getting healthcare due to the inability to pay was a

reason for loss of confidence in healthcare service (Rudzik, 2003). A World Bank (2010)

study in Nigeria equally identified that “lack of equipment and the cost of the service”

discouraged residents from seeking healthcare from primary healthcare centers (p. 31).

Access to healthcare is limited to residents who are unable to get adequate care or pay for

the services when available. Therefore residents do not find it encouraging to seek

healthcare in a facility without equipment and the services they cannot afford to pay.

Healthcare-worker attitude at the healthcare centers was another cause of

resident’s lack of confidence. Good health care begins with a warm and caring welcome

of the patient by healthcare workers. An Igbo adage says that asking, “How are you

doing?” to a sick person has healing power. As a result, Igbos place great importance on
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facial or emotional expression of their healthcare provider. People tend to interpret

others’ feelings and intentions through facial expressions, which give them insight as to

whether they are welcomed or respected. Penchansky and Thomas (1981) explained that

people will not seek healthcare if they feel unwelcome or unappreciated (not

accommodated) by the health clinic. The attitude of a service provider to clients

constitutes a barrier to accessing healthcare (Higgs et al., 2001). When people are sick,

they need compassion and care, rather than distress given to them by their providers.

In summary, residents’ loss of confidence in the primary healthcare system was a

result of absence of doctors, shortage of essential drugs, inadequately equipped facilities,

unaffordable cost of care, and staff lack of professionalism. For residents in Isu, the lack

of doctors and equipment in facilities translates to compromised care, which leaves them

feeling resentful. The lack of comprehensive care and the possibility of misdiagnoses

cause patients to lose confidence and limit their ability to seek care from the local

healthcare system (Rudzik, 2003). It can be argued, from all indications, that residents

will seek confidence in a system they trust can treat them well. The continued growth in

confidence in traditional healers is based on their affordability, accessibility,

accessibility, mutual respect, and holistic care (Bodeker et al., 2006; Simmons, 2011).

Potential Role of Community-Based Research in Primary Healthcare

Participants’ responses, shown under Theme Cluster 6, draw attention to the

desire of participants to be part of the healthcare decision-making process. Although

participants in this study felt that community involvement was an innovative idea,

healthcare providers and administrators have not previously used this option to assess the
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relevance of the local primary healthcare system to the community. No one person has a

dominion of ideas. Building a healthy community requires that diverse individuals are

brought together into community partnerships designed to find lasting solutions and to

establish connectedness based on mutual responsibility and respect (Higgs et al., 2001,

p. 3; World Bank, 2004b). Similar partnerships need be established in the Isu community

to incorporate various individual perspectives into efforts to improve the health of the

community. Results from this study indicate that community members have ideas that

could be used to bring about significant improvement in community access to healthcare

services. Not much can be achieved in any primary healthcare system without an

understanding of the needs or circumstances impacting how people benefit from the

healthcare system. Public health providers and administrators should, as a part of the

decision process, build local capacity and coalitions in the community to share

responsibilities and use available community resources toward the achievement of that

goal (Bartholomew, Parcel, Kok, & Gottlieb, 2008; Novick et al., 2008).

Community involvement in planning and implementing primary healthcare has

been perceived as necessary for an improved healthcare system and to ensure

accountability and better allocation of resources. However, most participants feared that

corruption keeps those who control primary healthcare from involving them. Involving

consumers in their own health decision-making process gives them power to control

factors that cause diseases and promotes facilities that cure those same diseases

(Regenstrief Center for Healthcare Engineering, 2006). The potential for community

involvement in their own healthcare decision and implementation process will help
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develop, build, and sustain an effective and empowered community:, engage the

community in dialogue, disseminate information, and mobilize people for action, and

enhance continued use of community primary healthcare services (Abdulraheem et al.,

2012).

The local healthcare system in Isu will benefit from the local health system when

healthcare providers, administrators, and residents share common information about the

healthcare system and local healthcare needs. Using community-based research will

improve the local system’s capacity-building and partnership in healthcare planning,

management, and use.

Applying the Conceptual Framework to the Results

This section will review whether primary healthcare services in Isu satisfy each of

the five dimensions of access to healthcare explained by Penchansky and Thomas (1981).

The availability dimension of healthcare access is not met in the local healthcare system,

which could not employ a full-time doctor, have qualified support staff, supply drugs, or

provide a variety of services that meet community needs. Access to healthcare is limited

or even denied when the extent of services offered by a healthcare system does not offer

services that meet the needs of the population (Cham et al., 2005). Themes 6, 8, 9, and 10

clearly indicated that the absence of a doctor on site and shortage of other qualified

support staff were serious setbacks for people to access the services they needed (Fan &

Habibov, 2009). Lateness to and absence from work among healthcare personnel equally

discouraged residents’ use and access to local healthcare services.

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Accessibility to healthcare services was limited by many problems, even though

healthcare centers were located in villages. Proximity alone does not constitute access to

healthcare (WHO, 2000a). Even though health centers and health posts are located in

close proximity to communities, most residents’ access to healthcare is still limited when

viewed from the perspective of Penchansky and Thomas’s (1981) understanding of

access. The benefit of proximal location of healthcare facilities to residents was lost when

pregnant women and residents were unable to get transportation to or from healthcare

centers in emergency situations. Responses from residents and healthcare providers

indicated that the ability to give care to clients has been limited greatly by the inability of

patients to access healthcare and by healthcare providers’ failure to extend care on time

during emergencies (Themes 7 and 8). The failure of the healthcare system to have an

ambulance or motorized public-transportation system was a great detriment to healthcare

access for the residents of Isu (World Bank, 1993).

People will seek care from a provider they consider to be sensitive to their values

and understand them. This is referenced as accommodation by Penchansky and Thomas

(1981). Using nurses, midwives, and CHEWs alone to provide primary healthcare

services was not conducive to the men and women who felt that their needs were beyond

healthcare-facility capabilities, and could not get treatment as needed (Liu & Dubinsky,

2000). Also, the attitude of some healthcare staff was not acceptable to most residents

and was among the factors that determined if they should return for sick care to the

healthcare center. Disrespect creates an impression of unacceptability in the mind of the

patient.
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Affordability is a key issue in the access to healthcare. Studies have implicated

cost of care (ability to pay) as having a great impact on accessibility and affordability of

healthcare (Long & Masi, 2009; Penchansky & Thomas, 1981). Residents of Isu pay for

healthcare services on a cash basis and usually at the point of service. There is no health

insurance or credit card system in use for Isu residents, so residents must pay out-of-

pocket at the point of service, and sometimes, payment is expected before care can begin.

Cost of care creates a deep lack in the ability of many rural residents and has been found

to be a major cause of impoverishment among low-income residents. It is not uncommon

among rural and low-income residents to be confronted with choosing between high-cost

healthcare, school fees for children, or paying for food (Jacobs, Ir, Bigdeli, Annear, &

Damme, 2012). Without the ability to pay, residents are more likely to postpone care, a

situation that is not helpful in critical or serious disease conditions. As a result, poor

residents who have been denied or refused treatment because of their inability to pay for

healthcare services considered the current healthcare system to be unacceptable.

Overall, the Isu local healthcare system is in need of repair to respond to

community needs and to manage its resources effectively within its current capacity.

Even though Isu has made tremendous efforts in providing services close to people, such

proximity and availability of infrastructure did not constitute access because of many

deficient elements in the system. Other concepts generated from this research directly or

indirectly impacted the degree of access residents have to healthcare. Themes 12, 13, 14,

19, 20, and 21 describe concepts that residents consider need attention to improve overall

access to healthcare in the community. Addressing these issues will result in a better
 133

policy and management of the healthcare system and will create new dimensions in

addressing healthcare challenges.

Isu residents will benefits from fewer healthcare centers that are well managed,

well provided, and maintained, and have qualified medical doctors and other allied staff.

This will enable healthcare providers and administrators the opportunity to review how

well the services met the needs of the community.

Limitations of the Study

This study is only preliminary research into the perceptions of participants

regarding access to primary healthcare in Isu. This study may not have exhausted all

perceptions of residents or produced comprehensive results in that (a) I designed the

instrument; a self-designed instrument may not have produced the best outcomes, (b) I

interviewed a small number of participants, (c) I spent a short time in gathering data and

limited my expenses, and (d) my experience may have affected data validity or

trustworthiness.

Implications for Social Change

I was prompted to conduct this study by the need to identify specific healthcare-

access issues and challenges in Isu and to discover means to address those issues and

challenges. Understanding the issues affecting residents’ access to healthcare will help to

inform local government leadership and stakeholders about the need to

• improve community participation in healthcare decision-making processes as

well as the implementation of healthcare services;

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• educate the community on primary healthcare services and tailor those

services to identified needs; and

• develop a ground-up model of a primary healthcare system using available

resources that satisfies the expressed needs of the people of rural Isu.

At a policy level, the findings from this study indicate that the crisis situation of

primary healthcare in Nigeria is also present in Isu. Problems of health access are not

generated in a vacuum but from the lived experiences of people in the community who

are impacted by the operation and provision of healthcare services. Results of this study

highlight the deficiencies in the ability of the primary healthcare system to provide

services for all ages and socioeconomic groups in the community. It will also provide

healthcare administrators, providers, and residents opportunities to seek change that will

improve access to healthcare delivery. The closeness of healthcare centers to residents is

a commendable improvement and demonstrates the primary healthcare system’s effort to

improve healthcare delivery. However, the primary healthcare system is not effective and

its capacity to provide needed services to the residents of Isu needs to be reevaluated. The

findings from this study point to the need for healthcare providers and administrators to

redefine primary healthcare in Isu in the community context of availability and

functionality, replacing the current discriminatory paradigm. Primary healthcare should

be offered from the perspectives of the consumers and not from that of the provider or

administrator alone.

I will share the final results of this study in presentations at appropriate academic

conferences and in papers in appropriate journals. I also will share the results of this
 135

study with stakeholders from the study site initially via e-mail and paper-copy

correspondence to the government healthcare chair and via paper-copy correspondence to

community leaders, pastors, and the leader of the traditional healers. I will ask the

government healthcare chair to share the study results with other healthcare

administrators as well as the nurses and midwives; I will ask community leaders and

pastors to share the study results with nurses, midwives, and residents; and I will ask the

leader of the traditional healers to share the study results with the traditional healers. I

also will conduct in-person, informational follow-up meetings and presentations during

subsequent visits to Nigeria and may do so in such locations as the (a) government

headquarters in Umundugba, (b) the traditional healers’ hall in Ekwe, and (c) the

community center in Nnerim.

Conclusion

The present state of PHC in Isu is deplorable. The current lack of doctors, basic drugs,

medical supplies, equipment and support staff is causing many Nigerians to live

unhappily, suffer diseases, and die prematurely from preventable causes. There is an

urgent need to align health programs and services with the healthcare needs of the

community. Administrators need to become aware that infrastructure or buildings alone

do not suffice for a primary healthcare system. PHC objectives in Isu cannot be achieved

unless administrators and providers address obstacles identified in this study that prevent

residents from accessing healthcare services, irrespective of their social, economic,

geographic, and cultural conditions. Access to healthcare services should always be

 136

explored in the context of the population or environment in which those services are

provided.

Many authors have shown that a lack of access to PHC inhibits the seeking of

appropriate care by the most vulnerable members of any community and ultimately is

responsible for poor health outcomes (Cohen et al., 2007; Hossen, 2010; WHO, 2008b).

For example, Kaseje (2006) estimates that 50% of the African population lacks access to

modern health facilities and, consequently, experiences low levels of immunization and

high levels of maternal, child, and infant mortality. The promise of PHC was always to

minimize the burden of disease in this vulnerable population (Cohen et al., 2007), but a

lack of access continues to prevent this promise from being realized. This study

demonstrates the many reasons why this continues to be the case in Isu.

Recommendations for Action

One area that needs immediate attention is the restructuring of the leadership of

the local health system and health department to ensure checks and balances. Policy and

planning decisions need to be informed by a committee that includes representatives from

the community, healthcare professionals, the local government primary health

department, and religious/humanitarian organizations, to ensure that policies and

programs are tailored to the needs of the community. Such an administrative structure

would ensure that various inputs are used in the management of healthcare-service

delivery, and that funds and resources are properly managed through better oversight,

more accountability, and checks and balances.

 137

The second area of action is to employ a permanent medical doctor at the primary

healthcare center. Results of this study show that many residents do not use the health

centers because there are no doctors on duty; a situation that has had adverse health

consequences. The local healthcare system, in the interim, can employ a full-time

physician who will be either centered at local government headquarters or visit

community health centers on a schedule, but with specific days at the headquarters.

Alternatively, the structure can include medical interns from the state university to

provide services at the health centers.

Third, the local healthcare system should establish a cooperative arrangement

between the PHC system and traditional healers. This will promote a better working

relationship between them, and enable the local health system to assess and utilize the

potentials of traditional healers in primary healthcare system. A closer relationship

would promote understanding, offer opportunities for training traditional healers on basic

hygiene, and recognize that traditional healers are well placed to offer certain specialized

services in the community. According to WHO (2009), primary healthcare should include

collaboration between physicians and traditional healers, so that together they can

respond to the expressed health needs of the community. Traditional healers can promote

access to care and complement the services of the local primary healthcare system..

The fourth recommendation is to create a program of public of public health

education and home visits. By employing more CHEWs, the local health system can

provide home visits, create service awareness, and conduct health education and health

promotion in the community. This program should also be equipped with a mobile clinic
 138

capability to take care of emergent cases that may arise during visits and at other needed

times.

The fifth recommendation is to provide all healthcare centers with water, power,

basic equipment and medical supplies. It is equally important that healthcare facilities be

maintained and kept in clear manner and be comfortable.

The sixth recommendation is for the PHC system should broaden its view of

primary healthcare with the input of healthcare workers and residents, and in accordance

with international PHC standards.

Finally, the local healthcare system must find a way to subsidize care for the most

vulnerable members of the community, so that serious cases can be treated without

asking for money before saving lives. Considering the nature of community, the local

health system can work with traditional leaders and village heads on how to collect

money from patients after such life-endangering threats have been averted.

These recommendations can be accomplished if the local government can set

aside a certain percent of its monthly allocation from the Federal Account for primary

healthcare services. In addition, the local government can levy a certain amount on all

taxable adults in the community to support its PHC program.

Recommendations for Further Research

Research should be conducted to more thoroughly examine the delivery of and

access to primary healthcare in Isu with regard to the use of community-based research—

in particular, the delivery and implementation of a community-feedback protocol to share

 139

concerns and ideas with the local government as a means of providing direction for

improvement of the primary healthcare system. Additional studies should be conducted to

determine how healthcare administrators and providers can best foster positive resident

attitudes toward the local primary healthcare system, which could lead to improved

resident-confidence levels in the system and thus improved resident access to primary

healthcare.

As a way to remedy the shortage of physicians in rural areas, I suggest that

research should be conducted on how nurses, midwives, and health extension workers

can receive additional advanced training to improve their skill and knowledge base. This

advanced training would put them in a position to manage rural primary healthcare

facilities during times of physician shortages.

Final Thought

Conducting research is often exciting to the beginner. This situation may cause

the researcher to delve into an area quite unknown. The actual research process brings the

reality of delving to the unknown to solve a problem. Situations often considered simple

become intense, challenging tasks; such is a doctoral dissertation. My research was

motivated by passion. I had difficulties in many ways, but the hope of bringing the

problem of my community to a worldview encouraged me to continue in the face of

difficulties. My advice to future students is to choose a simpler topic that can be

researched in a short period of time.

 140

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World Health Organization. (2000a). General guidelines for methodologies on research

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http://www.who.int/medicines/areas/traditional/definitions/en/index.html

World Health Organization. (2000b). The world health report 2000—Health systems:

Improving performance. Retrieved from http://www.who.int/whr/2000/en/

World Health Organization. (2000c). World Health Organization assesses the world’s

health systems. Retrieved from

http://www.who.int/whr/2000/media_centre/press_release/en/
 164

World Health Organization. (2003). Primary health care 25 years after Alma-Ata.

http://gis.emro.who.int

World Health Organization. (2004). WHO welcomes South Africa’s commitment to

traditional medicine. Retrieved from http://www.afro.who.int

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people. Retrieved from http://www.who.int/bulletin/africanhealth/en/index.html

World Health Organization. (2007). People-centered health care: A policy framework.

Retrieved from http://www2.wpro.who.int/sites/pci/publications.htm

World Health Organization. (2008a). Nigeria still searching for right formula. Bulletin of

the World Health Organization, 86. doi:10.1590/S0042-96862008000900006

World Health Organization. (2008b). The world health report 2008: Primary health care

now more than ever. Retrieved from http://www.who.int/whr/2008/en/index.html

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http://www.who.int/mediacentre/events/2009/wha62/en/index.html

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http://www.who.int/hia/evidence/doh/en/index.html

World Health Organization, Country Office for Africa. (2007). WHO country office

Nigeria annual report 2007. Retrieved from

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scenario. Retrieved from http://www.whoindia.org

 165

Yin, R. K. (2003). Case study research: Design and methods (3rd ed.). Thousand Oaks,

CA: Sage.
 166

Appendix A: Recruitment Flyer—Original Version

You may be able to help improve

access to healthcare in Isu.
How can you help?
 Share your opinion about healthcare practices and access to healthcare
care in Isu.
 Describe what you know about healthcare in the Isu community.
 Explain what you expect from the local government primary healthcare
services.

Who can participate?

 Nurses/midwives with 3 or more years of experience who work at the
community health centers, healthcare posts, or maternity clinics.
 Traditional healers who live in Isu and have provided healthcare to the
people for a minimum of 5 years.
 Residents of Isu 18 years and older who have lived in Isu for 5 or more
years.

How do I find out more or sign up to participate?

 Contact the researcher, Raymond Chimezie, in Nnerim Ndugba.
 Attend an informational meeting:
o nurses/midwives: local government headquarters (date, time or
date, time).
o traditional healers: traditional healers hall, (date, time or date,
time).
o residents: community center, (date, time or date, time).
 167

Appendix B: Recruitment Flyer—Igbo Translation

b fl ill

,
 168

Appendix C: Recruitment Flyer—Back Translation

Your Help May Improve Access to Healthcare in Isu!

How You May Help!

• Share what you know about healthcare services and how convenient it serves

your needs.

• Describe your opinions and all you know about healthcare in the Isu

community.

• State exactly what you expect from the government primary healthcare

services in Isu.

Who Can Participate?

• Nurses/midwives with 3 or more years of experience in healthcare delivery,

and who work at the local government community primary healthcare centers.

• Traditional healers or herbalists, who live in and provide services to the

people of Isu.

• Residents of Isu who are 18 years or more in age, and live in Isu for 5 years or

more.

How Do I Find Out More or Sign Up to Participate?

• Contact the researcher, Raymond Chimezie, in Nnerim Ndugba.

• Come to an informational meeting:

Nurses and midwives: come to the local government headquarters, Umundugba

(Date…., Time….).
 169

Traditional healer/herbalist: come to the traditional healer hall, Ekwe (Date…,

Time…).

Residents: come to the community center (Date…; Time….).

 170

Appendix D: Interview Questions for Government Healthcare Administrators

(including the local government chairman)

Name and Title of Administrator:

Date:

Thank you for agreeing to be interviewed about your perceptions regarding residents’

access to local primary health care services in rural Isu.

RQ1(background information)

1. How would you describe the government primary healthcare in this

community?

2. What kinds of people use government healthcare services the most?

RQ1a

3. What are the objectives of the government’s local primary healthcare system,

and how well are you achieving them?

4. What do you perceive to be the level of confidence that residents have in the

government’s local healthcare services?

RQ1b & 1c

5. What do you perceive to be the main challenges or barriers that affect

residents’ access to healthcare, and what solutions could you suggest?

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6. What procedures are in place to accommodate residents’ complaints or reports

about poor service?

RQ1d

7. What do you see as the role of traditional healers in primary healthcare for

residents?

8. What benefit do you see for meeting with local traditional healers to discuss

how to improve local health services? Would you be willing to do so?

RQ3

9. In your opinion, what is the value of asking nurses, midwives, and community

members for their views about healthcare services?

Conclusion: Is there anything else you would like to tell me about?

Thank you for your time. I will be showing you the results of our discussion at our next

meeting.
 172

Appendix E: Focus Group Questions for Nurses and Midwives

Names and Titles of Participants:

Date:

Thank you for agreeing to be interviewed about your perceptions regarding residents’

access to local primary health care services in rural Isu.

RQ1(background information)

1. How would you describe the government primary care services you offer?

2. What kinds of people use your services the most?

RQ1a

3. What are the health objectives of the services you provide, and how well are

you achieving them?

4. What do you perceive to be the level of confidence that residents have in your

services?

RQ1b & 1c

5. What do you perceive to be the main challenges or barriers that affect

residents’ access to healthcare, and what solutions could you suggest?

6. What procedures are in place to accommodate residents’ complaints or reports

about your services?

 173

RQ1d

7. What do you see as the role of traditional healers in primary healthcare for

residents, and to what extent do you work with traditional healers?

8. What benefits do you see to meeting with local traditional healers to discuss

how to improve local health services? Would you be willing to do so?

RQ3

9. In your opinion, what is the value of asking community members their views

about healthcare services?

Conclusion: Is there anything else you would like to tell me about?

Thank you for your time. I will be showing you the results of our discussion at our next

meeting.
 174

Appendix F: Focus Group Questions for Traditional Healers—Original Version

Names and Titles of Participants:

Date:

Thank you for agreeing to be interviewed about your perceptions regarding residents’

access to local primary health care services in rural Isu.

RQ1(background information)

1. How would you describe the services you provide to this community?

2. What kinds of people use your services the most?

RQ1d

3. What do you perceive to be the objectives of the government’s local primary

healthcare system, and how well do you think those objectives are being met?

4. What do you perceive to be the main challenges in providing the healthcare

people need, and what solutions can you suggest?

5. What do you see as the role of traditional healers in primary healthcare for

residents, and to what extent do you work with the government?

6. What is your relationship to the government’s primary healthcare services?

7. What do you see as the benefits to meeting with local healthcare providers to

discuss how to improve local health services? Would you be willing to do so?
 175

8. What benefits to you see to providing services to residents if they were

referred to you for special care by a government facility? Would you be

willing to do so?

9. What do you do when you are not capable of handling a particular case?

10. What benefits do you see to referring cases beyond your expertise to the

government health centers and other traditional healers? Would you be willing

to do so?

RQ3

11. In your view, what is the value of asking community members their views

about healthcare services?

Conclusion: Is there anything else you would like to tell me about?

Thank you for your time. I will be showing you the results of our discussion in our next

meeting.
 176

Appendix G: Focus Group Questions for Traditional Healers—Igbo Translation

(Ntoola Okwu)
 177

Appendix H: Focus Group Questions for Traditional Healers—Back Translation

RQ 1 (background information)

1. Could you describe the type of healthcare services you render to this

community?

2. Who are the people who use your services most?

RQ 1d

3. What reasons do you think that government has in mind for setting up local

healthcare services? How can you explain whether these reasons are being

accomplished or not?

4. What do you perceive to be the main challenges in providing the healthcare

people need, and what solutions can you suggest?

5. How would you describe the role of traditional healers in providing primary

healthcare services to Isu residents? To what extent have you collaborated

with the local government in your role as healthcare providers?

6. Describe your relationship with the government primary healthcare services?

7. What would be the benefits for meeting with local government healthcare

providers to discuss means of improving community healthcare services?

Would you be prepared to do so?

8. What would be the benefits if government healthcare providers referred some

special cases to your traditional care? Would you be willing to accept such a

relationship?
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9. What do you do when you are incapable of handling or treating a particular

sickness from a client?

10. What would be the advantage of referring cases beyond your competence to

the government primary healthcare center and to other traditional healers?

Would you be willing to do so?

RQ 3

11. What is your opinion about asking community members their views regarding

the nature of healthcare services provided to them in Isu Local Government

Area?

Conclusion: Do you have any other thing you would like to share or comment about

healthcare in Isu Local Government Area?

Thank you for your time and contribution. The result of our discussion will be shared

with you all during our next meeting.

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Appendix I: Focus Group Questions for Residents—Original Version

Names and Titles of Participants:

Date:

Thank you for agreeing to answer a few questions about your perceptions regarding

residents’ access to local primary health care services in rural Isu.

RQ2(background information)

1. How do you or your family get healthcare when you are sick?

RQ2a

2. Which government healthcare facilities do you or your family use, and under

what circumstances?

3. In what circumstances do you or your family use a traditional healer for

healthcare services?

4. In what ways do the government healthcare services meets your needs?

5. Please describe an experience when you were unable to get the care you

needed from the government healthcare system.

RQ2b & 2c

6. What do you perceive to be the main problems in people getting the

healthcare they need, and what solutions can you suggest?

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RQ2d

7. What is your level of confidence in the government healthcare system?

8. What is your level of confidence in traditional healers?

RQ3

9. What in your view is the value of asking community members their views

about healthcare services?

Conclusion: Is there anything else you would like to tell me about?

Thank you for your time. I will be showing you the results of our discussion in our next

meeting.
 181

Appendix J: Focus Group Questions for Residents—Igbo Translation

 182

Appendix K: Focus Group Questions for Residents—Back Translation

RQ 2 (Background Information)

1. Explain how you and/or your family receive healthcare when you are sick?

RQ 2a

2. Which government healthcare center do you or your family use, and under

what conditions?

3. Under what conditions would you or your family seek healthcare from a

traditional healer?

4. In what ways do the government healthcare services satisfy your health

needs?

5. Could you describe a time or circumstance in which the government

healthcare delivery system failed to meet your need or that of your family

member?

RQ 2b & 2c

6. What do you understand to be the major hindrances people encounter in

getting the needed healthcare they want from the local government healthcare

service? What suggestions do you have to remove these hindrances?

RQ 2d

7. How can you describe your trust or confidence in the healthcare services

provided by the government in Isu?

8. To what extent do you trust the services of traditional healers?

RQ 3
 183

9. What is your opinion about asking community members their views regarding

the nature of healthcare services provided to them in Isu Local Government

Area?

Conclusion: Do you have any other thing you would like to share or comment about

healthcare in Isu Local Government Area?

Thank you for your time and contribution. The result of our discussion will be shared

with you all during our next meeting.

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Appendix L: Letter of Introduction—Chairman

Chairman

Isu Local Government Area

Umundugba, Imo State, Nigeria

May 2012

Dear Chairman,

My name is Raymond O. Chimezie and I am a doctoral candidate at Walden University.

For my doctoral research, I am interested in conducting a study on the perceptions of Isu

community residents and healthcare providers regarding residents’ access to current

primary healthcare services provided by the government. Research studies have

demonstrated that certain populations do not access available healthcare for a variety of

reasons and often with negative outcomes. What is not known, however, is (a) how Isu

residents’ access to healthcare is perceived by both those residents and healthcare

providers, (b) whether such perceptions could be affecting their use of government

healthcare services, and if so, (c) what healthcare model might better express the primary

healthcare needs of the population. To answer these questions, I would like to interview

you and three other healthcare administrators in your office. I also would like to

interview nurses and midwives, traditional healers, and residents and will contact local
 185

community leaders and pastors to seek support in this area. I have received the

appropriate permissions to collect data, and I will keep all data confidential.

I have intended this letter to serve as a means of both introducing myself and requesting

support for my data collection efforts. This research is important because it will provide

insight into what residents perceive about available primary healthcare services as well as

barriers or challenges to providing effective healthcare for these residents. Your

assistance in conducting this research is critical. Should you have any questions, I can be

reached by phone at 1-510-703-7798 or by e-mail at [email protected].

Sincerely,

Raymond Chimezie

Doctoral Candidate

Walden University
 186

Appendix M: Letter of Introduction—Community Leader/Pastor

Community Leader/Pastor

Nnerim Autonomous Community

Isu Local Government Area

Umundugba, Imo State, Nigeria

May 2012

Dear HRH Eze Stanley Egbe,

My name is Raymond O. Chimezie and I am a doctoral candidate at Walden University.

For my doctoral research, I am interested in conducting a study on the perceptions of Isu

community residents and healthcare providers regarding residents’ access to current

primary healthcare services provided by the government. Research studies have

demonstrated that certain populations do not access available healthcare for a variety of

reasons and often with negative outcomes. What is not known, however, is (a) how Isu

residents’ access to healthcare is perceived by both those residents and healthcare

providers, (b) whether such perceptions could be affecting their use of government

healthcare services, and if so, (c) what healthcare model might better express the primary

healthcare needs of the population.

 187

To answer these questions, I would like to interview nurses and midwives and residents

in your community. I also would like to interview government healthcare administrators

and traditional healers, and I will contact the appropriate offices to seek support in this

area. I have received the appropriate permissions to collect data, and I will keep all data

confidential.

I have intended this letter to serve as a means of both introducing myself and requesting

support for my data collection efforts. I hope that you will post my recruitment flyer in

public community areas as well as distribute the flyer to residents as it is feasible. This

research is important because it will provide insight into what residents perceive about

available primary healthcare services as well as barriers or challenges to providing

effective healthcare for these residents. Your assistance in conducting this research is

critical, and I anxiously await your feedback. Should you have any preliminary questions,

I can be reached by phone at 1-510-703-7798 or by e-mail at

[email protected].

Sincerely,

Raymond O. Chimezie

Doctoral Candidate

Walden University
 188

Appendix N: Letter of Introduction—Leader of Traditional Healers

Leader of Traditional Healers

Nnerim Autonomous Community

Isu Local Government Area

Umundugba, Imo State, Nigeria

May 2012

Dear Sir,

My name is Raymond O. Chimezie and I am a doctoral candidate at Walden University.

For my doctoral research, I am interested in conducting a study on the perceptions of Isu

community residents and healthcare providers regarding residents’ access to current

primary healthcare services provided by the government. Research studies have

demonstrated that certain populations do not access available healthcare for a variety of

reasons and often with negative outcomes. What is not known, however, is (a) how Isu

residents’ access to healthcare is perceived by both those residents and healthcare

providers, (b) whether such perceptions could be affecting their use of government

healthcare services, and if so, (c) what healthcare model might better express the primary

healthcare needs of the population.

 189

To answer these questions, I would like to interview traditional healers in your

community. I also would like to interview government healthcare administrators, nurses

and midwives, and residents, and I will contact the appropriate offices to seek support in

this area. I have received the appropriate permissions to collect data, and I will keep all

data confidential.

I have intended this letter to serve as a means of both introducing myself and requesting

support for my data collection efforts. I hope that you will distribute my recruitment flyer

to traditional healers in your area. This research is important because it will provide

insight into what residents perceive about available primary healthcare services as well as

barriers or challenges to providing effective healthcare for residents of Isu. Your

assistance in conducting this research is critical, and I anxiously await your feedback.

Should you have any preliminary questions, I can be reached by phone at 1-510-703-

7798 or by e-mail at [email protected].

Sincerely,

Raymond O. Chimezie

Doctoral Candidate

Walden University
 190

Appendix O: Letters of Support From Community Leaders

191
 192

Appendix P: Data Collection and Analysis Procedures

Prior to visit: Community leaders will post recruitment flyers and pastors will

distribute flyers to parishioners.

Day 1: Visit personally with the local government chairman, local community

leaders, pastors, and the leader of the traditional healers and confirm arrangements to

hold two informational meetings in the community center. Confirm interview with the

chairman for the following day. Conduct first informational meetings (one in English for

the nurses/midwives and one in Igbo for the traditional healers and residents with

translation as needed for individual participants in either group).

Day 2: Conduct interview with the chairman and confirm arrangements to

interview the two other healthcare administrators the following day. Schedule debriefing

and member checking session for Day 28. Begin transcribing chairman’s interview. Post

additional flyers in the community. Network with nurses/midwives, traditional healers,

and residents (potential participants) to personally promote my study and encourage

resident participation (build trust and recruit participants).

Day 3: Conduct interviews with remaining two healthcare administrators.

Schedule debriefing and member checking sessions for Day 28. Begin transcribing

healthcare administrators’ interviews. Continue networking nurses/midwives, traditional

healers, and residents (potential participants).

Day 4: Continue transcription of interviews and begin preliminary data analysis.

Continue networking with nurses/midwives, traditional healers, and residents (potential

participants).
 193

Day 5: Complete transcription of interviews and begin preliminary data analysis.

Continue networking with nurses/midwives, traditional healers, and residents (potential

participants).

Day 6: Continue data analysis of interview transcripts. Continue networking with

nurses/midwives, traditional healers, and residents (potential participants). Schedule

focus groups for Days 8-11: 6 (nurses and midwives), 6 (traditional healers), 6 (male

residents), and 6 (female residents), respectively. Conduct second informational meetings

(one in English for the nurses/midwives and one in Igbo for the traditional healers and

residents with translation as needed for individual participants in either group).

Day 7: Continue data analysis of interview transcripts. Continue networking with

nurses/midwives, traditional healers, and residents (potential participants).

Days 8–11: Conduct focus groups and begin transcription of focus group

responses. Schedule debriefing and member checking sessions for Days 29 (nurse and

midwives, and traditional healers) and Day 30 (male and female residents).

Days 12–15: Complete transcription of focus group responses.

Days 16–22: Complete data analysis of focus group transcripts (and interviews if

needed).

Day 23: Provide a sample of data to second coder for analysis.

Days 25–26: Compare my analysis with that of the second coder to determine

inter-coder reliability and make adjustments as appropriate.

 194

Day 28: Conduct debriefing and member checking sessions with the chairman and

three healthcare administrators. Begin making adjustments to interpreted data based on

participant feedback.

Day 29: Conduct debriefing and member checking sessions with the nurses and

midwives, and traditional healers. Begin making adjustments to interpreted data based on

participant feedback.

Day 30: Conduct debriefing and member checking sessions with the male and

female residents. Begin making adjustments to interpreted data based on participant

feedback.

Day 30–31: Complete adjustments to interpreted data based on participant

feedback.
 195

Appendix Q: National Institutes of Health Certificate

 196

Appendix R: Second-Coder Confidentiality Agreement

Confidentiality Agreement for Second Coder

Name of Signer: Desmond Oparaku
During the course of my activity in collecting and coding data for the research
Perceptions of Rural Residents and Healthcare Providers in Isu Local Government Area
of Imo State, Nigeria Regarding Access to Primary Healthcare Services for Rural
Residents: A Case Study, I will have access to information, which is confidential and
should not be disclosed. I acknowledge that the information must remain confidential,
and that improper disclosure of confidential information can be damaging to the
participant.

By signing this Confidentiality Agreement I acknowledge and agree that:

1. I will not disclose or discuss any confidential information with others, including
friends or family.
2. I will not in any way divulge, copy, release, sell, loan, alter or destroy any
confidential information except as properly authorized.
3. I will not discuss confidential information where others can overhear the
conversation. I understand that it is not acceptable to discuss confidential information
even if the participant’s name is not used.
4. I will not make any unauthorized transmissions, inquiries, modification or purging of
confidential information.
5. I agree that my obligations under this agreement will continue after termination of
the job that I will perform.
6. I understand that violation of this agreement will have legal implications.
7. I will only access or use systems or devices I’m officially authorized to access and I
will not demonstrate the operation or function of systems or devices to unauthorized
individuals.

By signing this document, I acknowledge that I have read the agreement and I agree to
comply with all the terms and conditions stated above.

Hand written signature: __________________________________ Date: __________

OR
 197

Electronic signature (email address): [email protected]__ Date: May 7, 2012_

 198

Appendix S: Consent form for Individual Interviews

Perceptions of Rural Residents and Healthcare Providers in Isu Local Government Area

of Imo State, Nigeria, Regarding Access to Primary Healthcare Services for Rural

Residents: A Case Study

You are invited to participate in a research study of perceptions of access to primary

healthcare for rural residents of Isu. You were selected as a possible participant because

of your knowledge and/or experience related to the topic. Please read this form and ask

any questions you may have before acting on this invitation to be in the study. This study

is being conducted by Raymond Chimezie, a doctoral candidate at Walden University,

Minnesota, Minneapolis, United States of America.

Background Information

The purpose of this study is to explore the perceptions of rural community residents and

healthcare providers (government healthcare administrators, nurses and midwives, and

traditional healers) regarding residents’ access to primary healthcare services in Isu and

to examine the benefit of using community-based research to promote resident use of

those healthcare services. Specifically, I will seek to gather information regarding (a) the

perceived accessibility, affordability, accommodation, acceptability, and availability of

government healthcare services, (b) characteristics of the healthcare system that both
 199

hinder and promote residents’ use of healthcare services, and (c) the potential for

community-based research to promote residents’ use of available healthcare services.

Procedures

If you are a healthcare administrator (chairman of the local government or hold a senior

administrative position in the local government healthcare), you will be asked to

participate in a face-to-face individual interview arranged in your office at the local

government headquarters. In addition, all participants will be asked to participate in a

follow-up session to be held approximately 1 week after participating in the interviews or

focus groups. During this follow-up session, I will share my preliminary findings and ask

for your feedback regarding my interpretation of the collected data. Each meeting will

last approximately 1 ½ hours.

Voluntary Nature of the Study

Your participation in this study is strictly voluntary and will not affect you adversely in

any way. Your identity will not be shared with any local government authority or

residents in Isu. You are free to withdraw from the study at any time without penalty of

any kind and your withdrawal will not affect your relationship with the investigator, the

local government, or Walden University.

Risks and Benefits of Being in the Study

 200

No anticipated risks are associated with participation in this study. However, in the event

you experience stress or anxiety during your participation in the study, you may terminate

your participation at any time. You may refuse to answer any questions you consider

invasive or stressful.

The potential benefit of participating in this study may come in the form of improved

primary healthcare delivery by the local government that will meet the expressed needs

of the residents of Isu and the inclusion of community residents in future primary

healthcare planning and implementation.

Compensation

There is no form of compensation for participation.

Confidentiality

The records of this study will be kept private. In any report of this study that might be

published, the researcher will not include any information that will make it possible to

identify any participant. Research records will be kept in a locked file; only the

researcher will have access to the records. Interviews will be digitally recorded for

purposes of providing accurate description of your experience. However, the recorded

data will be destroyed at the completion of the study, which will be within 1 year.

Hardcopy data will be destroyed after 5 years.

 201

Contacts and Questions

You may ask any questions you have now. If you have questions later, you may contact

the primary researcher Raymond Chimezie by phone at (510) 703-7798 or by e-mail at

[email protected]. You may also contact my advisor Dr. Michael Schwab

by phone at 1-800-925-3368 or by e-mail at [email protected]. The

Research Participant Advocate at Walden University is Dr. Leilani Endicott. You also

may contact her by phone at (800) 925-3368 (ext. 2393) or by e-mail at

[email protected].

Statement of Consent:

I have read the above information. I have asked questions and received answers. I will

receive a copy of this form from the researcher. I consent to participate in the study.

__________________________________________

Printed Name of Participant

__________________________________________ _________________

Signature of Participant Date

__________________________________________ _________________

Signature of Investigator, Raymond Chimezie Date

 202

Appendix T: Consent Form Focus Group—Original Version

Perceptions of Rural Residents and Healthcare Providers in Isu Local Government Area

of Imo State, Nigeria, Regarding Access to Primary Healthcare Services for Rural

Residents: A Case Study

You are invited to participate in a research study of perceptions of access to primary

healthcare for rural residents of Isu. You were selected as a possible participant because

of your knowledge and/or experience related to the topic. Please read this form and ask

any questions you may have before acting on this invitation to be in the study. This study

is being conducted by Raymond Chimezie, a doctoral candidate at Walden University,

Minnesota, Minneapolis, United States of America.

Background Information

The purpose of this study is to explore the perceptions of rural community residents and

healthcare providers (government healthcare administrators, nurses and midwives, and

traditional healers) regarding residents’ access to primary healthcare services in Isu and

to examine the benefit of using community-based research to promote resident use of

those healthcare services. Specifically, I will seek to gather information regarding (a) the

perceived accessibility, affordability, accommodation, acceptability, and availability of

government healthcare services, (b) characteristics of the healthcare system that both
 203

hinder and promote residents’ use of healthcare services, and (c) the potential for

community-based research to promote residents’ use of available healthcare services.

Procedures

If you are a nurse or midwife, a traditional healer, or a resident, you will be asked to

participate in a focus group discussion arranged in the local community center. In

addition, all participants will be asked to participate in a follow-up session to be held

approximately 1 week after participating in the interviews or focus groups. During this

follow-up session, I will share my preliminary findings and ask for your feedback

regarding my interpretation of the collected data. Each meeting will last approximately 1

½ hours.

Voluntary Nature of the Study

Your participation in this study is strictly voluntary and will not affect you adversely in

any way. Your identity will not be shared with any local government authority or

residents in Isu. You are free to withdraw from the study at any time without penalty of

any kind and your withdrawal will not affect your relationship with the investigator, the

local government, or Walden University.

Risks and Benefits of Being in the Study

No anticipated risks are associated with participation in this study. However, in the event

you experience stress or anxiety during your participation in the study, you may terminate
 204

your participation at any time. You may refuse to answer any questions you consider

invasive or stressful.

The potential benefit of participating in this study may come in the form of improved

primary healthcare delivery by the local government that will meet the expressed needs

of the residents of Isu and the inclusion of community residents in future primary

healthcare planning and implementation.

Compensation

There is no form of compensation for participation.

Confidentiality

The records of this study will be kept private. In any report of this study that might be

published, the researcher will not include any information that will make it possible to

identify any participant. Research records will be kept in a locked file; only the

researcher will have access to the records. Interviews will be digitally recorded for

purposes of providing accurate description of your experience. However, the recorded

data will be destroyed at the completion of the study, which will be within 1 year.

Hardcopy data will be destroyed after 5 years.

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Contacts and Questions

You may ask any questions you have now. If you have questions later, you may contact

the primary researcher Raymond Chimezie by phone at (510) 703-7798 or by e-mail at

[email protected]. You may also contact my advisor Dr. Michael Schwab

by phone at 1-800-925-3368 or by e-mail at [email protected]. The

Research Participant Advocate at Walden University is Dr. Leilani Endicott. You also

may contact her by phone at (800) 925-3368 (ext. 2393) or by e-mail at

[email protected].

Statement of Consent:

I have read the above information. I have asked questions and received answers. I will

receive a copy of this form from the researcher. I consent to participate in the study.

__________________________________________

Printed Name of Participant

__________________________________________ _________________

Signature of Participant Date

__________________________________________ _________________

Signature of Investigator, Raymond Chimezie Date

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Appendix U: Consent Form Focus Group—Igbo

Translation
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Appendix V: Consent Form Focus Group—Back Translation

Opinion of Residents and Healthcare Providers Regarding Access to Primary Healthcare

services in Isu Local Government Area, Imo State Nigeria: Isu Local Government Area

as a case of study.

You are called to participate in a research study to find out the opinion of the people in

Isu about their access to healthcare. You have been selected just as one of the participants

of this program in view of your wealth of knowledge and of your expertise about this

very topic. Please read carefully through this form and you may of course ask any

question before you honor this invitation about this study. The person conducting this

research is Raymond Chimezie, a doctorate degree student of Walden University,

Minnesota, Minneapolis, United States of America.

Background Information:

The aim of this research is basically to discover the awareness of the residents and

healthcare service providers (government health administrators, nurses and midwives,

and traditional healers) with regard to residents in Isu who will benefit from using

community-based research to enhance the awareness of residents in using healthcare

services.
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Precisely, this study will gather information about (a) the perceived accessibility,

affordability, accommodation, acceptability, and availability of health center around the

vicinity (b) things that hinder residents from patronizing the centers and things that

motivate residents’ interest in the healthcare centers and (c) what role community-based

research can play to empower or motivate residents zeal to use their healthcare services.

Procedures:

Nurses or midwives, traditional healers or residents will be asked to take part in the vital

group discussions organized in your local healthcare center. In addition, every participant

will be asked to join the subsequent discussion to be held one week after the previous

focus group meeting. During the follow-up discussion, I will relate to the people my

initial findings and also ask them for their views with regard to my interpretation of the

available data. We shall not spend more than 1 ½ hours on each meeting.

Voluntary nature of the study:

Your participation in this study is out of your freewill. Participants will not suffer any

risks in this study. None of your personal information will be shared with anybody in the

local government, Isu community, or any person in Isu. Any participant can stop

participating in this study at any time without any repercussion, and your discontinuing

will not affect your relationship with the researcher, the local government, or Walden

University.
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Risks and Benefits of Being in the study:

No risks will be encountered for those taking part in this study. In case you experience

any stress or anxiety when the study is in progress, you are free to withdraw. You are also

free to refuse answering any question that you find stressful or unnecessary.

The benefit we could get from participating in this study could be in the form of

improved healthcare delivery by the local government that will serve the needs of the

residents of Isu. It could make the local government to include the residents of Isu in the

future planning and implementation of the healthcare delivery.

Compensation:

Participants in this study will not be paid or receive any kind of reward.

Confidentiality:

Researcher’s records will be kept secret. The researcher will not include any information

in the report that could be traced to any person who participated in this study. The reports

of the researchers will be confidential; and only the researcher will be able to use or have

access to them. All interviews will be digitally recorded for the purpose of correct

documentation and understanding of your experiences. However, all the data in digital

format will be destroyed at the end of the study within one year, while written or

hardcopy records will be destroyed after 5 years.

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Contacts and Questions:

You may ask your questions now. If you have any questions later, please contact the lead

investigator, Raymond Chimezie at 510-703-7798 or by email at

[email protected]. You may also direct your questions to my supervisor

Dr. Michael Schwab by phone at 1-800-925-3368 or by email at

[email protected]. The Research Participants Advocate at Walden

University is Dr. Leilani Endicott. She can be reached at 1-800-925-3368 (ext. 2393) or

by email at [email protected].

Statement of Consent:

I have read and understood the information above. I have also asked questions and

received responses. I will receive a copy of this form from the researcher. I agree to

participate in the study.

__________________________________________

Printed Name of Participant

__________________________________________ _________________

Signature of Participant Date

__________________________________________ _________________

Signature of Investigator, Raymond Chimezie Date

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Appendix W: Example Coding Notes

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Curriculum Vitae

Raymond O. Chimezie

Richmond, CA 94801

[email protected]

Education

Doctor of Philosophy: Public Health - Community Health Promotion and Education

(expected graduation date: 6/2012)

Walden University: Minneapolis, MN

Master of Arts in Education: Instructional Leadership (2006)

Argosy University: San Francisco, CA

Certification

• California Multiple Subject Teaching Credential with CLAD (2006)

• Emergency Management Services Certifications: IS 00100.a and IS 00700.a (Civil

Air Patrol, USAF Auxiliaries, 3/2010)

Academic Employment

• Teacher, elementary and middle grades (2003–present)

West Contra Costa Unified School District, Richmond, CA

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Other Professional Experience

• Health educator (volunteer) Disease management outreach for patients and

community (2009–2011). Kaiser Permanente, Health Education Department, Pinole,

California.

• Member Chronic Disease Management Ethnic Health Institute of the Alter Bates

Summit Medical Center, Oakland, California (2011-present)

• Emergency and disaster management/control responder (volunteer), (2009-present)

Contra Costa Medical Reserve Corps, Contra Costa County, California

Presentations

Diabetes: Causes and Management. Presented at Barrett Terrace & Plaza Apartments

(residential facility), Richmond, CA. (10/27/11)

Membership

• United Teachers of Richmond, California. Health committee member. (2009–2011).

• Nigerian Institute of Management (1991-present)