Short and longer-term impacts of health insurance on catastrophic health expenditures in Kwara State, Nigeria.

BACKGROUND: Out- of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE. METHODS: The analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP). RESULTS: Using 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p < 0.05), while the effect on insured households was 5.7 pp (p < 0.05). The longer-term impact four years after program introduction was not significant. Heterogeneity analyses show a reduction in CHE of 7.2 pp (p < 0.01) in the short-term for the poorest tercile. No significant effects were found for the middle and richest terciles, nor in the longer-term. Households with a chronically ill member experienced a reduction in CHE of 9.4 pp (p < 0.01) in the short-term, but not in the longer-term. Most estimates based on the 40% of CTP measure were not statistically significant. CONCLUSION: These findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.

Prevalence and determinants of stress of informal caregiving: A cross-sectional study among informal caregivers of hospitalised patients in a tertiary hospital in Nigeria.

BACKGROUND: Caring for patients in the hospital can cause a lot of stress for the caregivers, especially those who are involved with informal caregiving such as family members. Little is known in Nigeria on the stress of informal caregiving in the hospital environment. This study assessed the informal caregivers' stress level and their determinants in a tertiary hospital in Ilorin, Nigeria. METHODOLOGY: This was a hospital-based cross-sectional study. Between September and October 2019, using a simple random sampling method, data were collected from 400 informal caregivers of patients in University of Ilorin Teaching Hospital with interviewer-administered questionnaire which included socio-demographic characteristics, Caregivers Strain index (CSI) and caregivers' stress from institution and other factors index (CSIOI). Analysis was performed, and prevalence and determinants of stress of informal caregiving were presented using descriptive statistics and logistic regressions. P < 0.05 was considered statistically significant. RESULTS: The majority, 381 (95.2%) of the informal caregivers, reported great stress levels using CSI, while 227 (56.7%) experienced a great level of stress with the CSIOI. Predictors of caregiver stress were perception that staying around was stressful (odds ratio [OR] - 17.5, P < 0.001), felt their patients will not be well cared for if not around (OR - 6.1, P < 0.001), staying at the hospital for >30 days (OR - 2.6, P = 0.001). CONCLUSION: The informal caregivers experienced a great level of stress taking care of their patients on admission in the hospital. It is, therefore, expedient that issues surrounding the comfort of the informal caregivers as they care for their patients should be included in hospital policies.

The risk perception of COVID-19 and vaccine uptake among patients with chronic illnesses at a tertiary health facility in Nigeria.

Objectives: This study assessed the risk perception of COVID-19 and the uptake of the COVID-19 vaccine among patients with chronic illnesses in a tertiary health facility. Design: A hospital-based cross-sectional study. Setting: The outpatient clinics in a tertiary health facility in Ilorin, North-Central Nigeria. Participants: Patients with chronic diseases attending outpatient clinics in UITH, Ilorin from November- December 2022, excluding patients under 18 years of age, using simple random sampling by balloting for outpatient clinics, proportional allocation for participants from each clinic, and systematic sampling method for eligible respondents. Main outcome measure: Risk perception of COVID-19 and vaccine uptake among patients with chronic illnesses in Nigeria. Results: Respondents believed that older people were most at risk of COVID-19. Over two-thirds, 278 (69.5%) of the respondents had received the COVID-19 vaccine. Fear of the unknown (36.0%) and fear of side effects 30 (24.6%) were the most common reasons for not taking the vaccine. Those married were more likely to have received at least one dose of the vaccine (p=0.007). Conclusion: COVID-19 risk perception and COVID-19 vaccine uptake were relatively above average. Fear of the unknown and side effects were significant reasons for not taking the vaccines. Funding: None declared.

Handling client financial insolvency in maternity services: An occurrence, experience and policy gap qualitative analysis among healthcare stakeholders in North-Central Nigeria.

OBJECTIVE: To assess the occurrence of client financial insolvency, experiences of key healthcare stakeholders, and policy gaps on handling the situation during maternity services. METHODS: A qualitative study was conducted in North-Central Nigeria. Participants were key healthcare stakeholders including healthcare workers from private, primary, secondary, and tertiary facilities, healthcare administrators/facility-heads, program managers and policy makers at local and state government levels through In-depth and Key Informant interviews. Identified themes were occurrence, experiences of stakeholders, and prevention of client financial insolvency. Data were analyzed with the Nvivo statistical package. RESULTS: Participants confirmed the occurrence of client financial insolvency. Clients' inability to pay hospital bills was due to being indigent, awaiting support from relations, or clients who were uncommitted to the payment. Health facilities lack guiding policy documents; potential cases are referred from private to public or from primary to secondary/tertiary facilities. Methods of handling financial insolvency included healthcare worker-related (staff scavenging for needed consumables, fund-raising among facility staff), facility-related (revolving fund, medical social welfare, welfare committee, discharge with re-payment plan, fee-waiver), community-related (ward development committee, religious organizations/philanthropists) interventions, or hospital detention of insolvent clients. Although clients' bills did not increase during detention, many clients did not honor post-discharge re-payment agreements. Participants suggested a client-friendly billing system, early initiation of birth preparedness, partner involvement, and a rapid scale-up of health insurance for pregnant women to curb financial insolvency. CONCLUSION: Tackling client financial insolvency requires policy documents, support to private facilities, effective debt-recovery mechanisms, and scale up of health insurance for pregnant women.

Knowledge and practice of post-exposure prophylaxis (PEP) against HIV infection among health care providers in a tertiary hospital in Nigeria.

OBJECTIVE: To assess the knowledge and practice of post exposure prophylaxis (PEP) against HIV infection among health care providers in University of Abuja Teaching Hospital (UATH). METHODS: A cross-sectional survey conducted on 230 health care providers in UATH. RESULTS: Majority (97.0%) of the respondents have heard about PEP, but only a few (30.9%) of them could correctly identify the drugs used and duration of PEP. A third of respondents have had one form of accidental exposure or the other. HIV test was carried out in about two-thirds (64.8%) of the source patients. Thirteen (28.3%) of the source patients were HIV-positive. Of the 13 respondents that were exposed to HIV-positive patients, only 3 (23.1%) received PEP, and these three completed PEP, while majority, 10/13 (76.9%) did not receive PEP in spite of their exposure to HIV-positive sources. CONCLUSION: The study shows that the knowledge and practice of PEP among health care providers are very poor.

Outcome of vision screening by community health workers at immunization outlets in Nigeria to support access to early visual evaluation in children aged 0-2 years.

PURPOSE: Routine eye examination in early life is not the practice in most resource-limited countries. Delay in the presentation for eye problems is typical. Community health officers are often consulted by caregivers for all health problems during routine immunization and well-baby clinics in primary healthcare for children aged 0-2 years. This study evaluated the value and limitation of interview, Bruckner red reflex test, and instrument vision screener by noneye care middle-level staff of rural and urban well-baby immunization clinics, in early detection and referral for childhood eye disorders. MATERIALS AND METHODS: This was a cross-sectional study. Middle-level community health workers (CHWs) working at well-baby/immunization clinics were trained to perform vision screening using interview of caregivers, red reflex eye examination with ophthalmoscope, and instrument vision screener (Welch Allyn SPOT™ Vision Screener) without mydriatic drugs during routine immunization of children aged 0-2 years. IRB approval was obtained. RESULTS: Over a 6-month period in 2017, the CHWs screened 5609 children. Overall, 628 (11.2%) patients were referred to the tertiary child eye care unit. Referred cases included cataract, glaucoma, congenital nasolacrimal duct obstruction, ophthalmia neonatorum, retinoblastoma, and significant refractive errors. Referral from the interview of mothers was enhanced if specific questions to elicit visual function were asked. Bruckner red reflex test was more effective than instrument vision screener in the detection of cataract and life-threatening diseases such as retinoblastoma. Instrument vision screener was preferred by parents and better at detecting amblyopic risk factors. CONCLUSION: Preschool vision screening during routine immunization by primary healthcare workers in resource-limited settings was effective. Whenever instrument vision screener does not give any recommendation during screening, consider vision- or life-threatening pathology and refer.

The prominent role of informal medicine vendors despite health insurance: a weekly diaries study in rural Nigeria.

In sub-Saharan Africa, accessibility to affordable quality care is often poor and health expenditures are mostly paid out of pocket. Health insurance, protecting individuals from out-of-pocket health expenses, has been put forward as a means of enhancing universal health coverage. We explored the utilization of different types of healthcare providers and the factors associated with provider choice by insurance status in rural Nigeria. We analysed year-long weekly health diaries on illnesses and injuries (health episodes) for a sample of 920 individuals with access to a private subsidized health insurance programme. The weekly diaries capture not only catastrophic events but also less severe events that are likely underreported in surveys with longer recall periods. Individuals had insurance coverage during 34% of the 1761 reported health episodes, and they consulted a healthcare provider in 90% of the episodes. Multivariable multinomial logistic regression analyses showed that insurance coverage was associated with significantly higher utilization of formal health care: individuals consulted upgraded insurance programme facilities in 20% of insured episodes compared with 3% of uninsured episodes. Nonetheless, regardless of insurance status, most consultations involved an informal provider visit, with informal providers encompassing 73 and 78% of all consultations among insured and uninsured episodes, respectively, and individuals spending 54% of total annual out-of-pocket health expenditures at such providers. Given the high frequency at which individuals consult informal providers, their position within both the primary healthcare system and health insurance schemes should be reconsidered to reach universal health coverage.

The effect of health insurance and health facility-upgrades on hospital deliveries in rural Nigeria: a controlled interrupted time-series study.

BACKGROUND: Access to quality obstetric care is considered essential to reducing maternal and new-born mortality. We evaluated the effect of the introduction of a multifaceted voluntary health insurance programme on hospital deliveries in rural Nigeria. METHODS: We used an interrupted time-series design, including a control group. The intervention consisted of providing voluntary health insurance covering primary and secondary healthcare, including antenatal and obstetric care, combined with improving the quality of healthcare facilities. We compared changes in hospital deliveries from 1 May 2005 to 30 April 2013 between the programme area and control area in a difference-in-differences analysis with multiple time periods, adjusting for observed confounders. Data were collected through household surveys. Eligible households ( n = 1500) were selected from a stratified probability sample of enumeration areas. All deliveries during the 4-year baseline period ( n = 460) and 4-year follow-up period ( n = 380) were included. FINDINGS: Insurance coverage increased from 0% before the insurance was introduced to 70.2% in April 2013 in the programme area. In the control area insurance coverage remained 0% between May 2005 and April 2013. Although hospital deliveries followed a common stable trend over the 4 pre-programme years ( P = 0.89), the increase in hospital deliveries during the 4-year follow-up period in the programme area was 29.3 percentage points (95% CI: 16.1 to 42.6; P < 0.001) greater than the change in the control area (intention-to-treat impact), corresponding to a relative increase in hospital deliveries of 62%. Women who did not enroll in health insurance but who could make use of the upgraded care delivered significantly more often in a hospital during the follow-up period than women living in the control area ( P = 0.04). CONCLUSIONS: Voluntary health insurance combined with quality healthcare services is highly effective in increasing hospital deliveries in rural Nigeria, by improving access to healthcare for insured and uninsured women in the programme area.

The Financial Burden of Non-Communicable Chronic Diseases in Rural Nigeria: Wealth and Gender Heterogeneity in Health Care Utilization and Health Expenditures.

OBJECTIVES: Better insights into health care utilization and out-of-pocket expenditures for non-communicable chronic diseases (NCCD) are needed to develop accessible health care and limit the increasing financial burden of NCCDs in Sub-Saharan Africa. METHODS: A household survey was conducted in rural Kwara State, Nigeria, among 5,761 individuals. Data were obtained using biomedical and socio-economic questionnaires. Health care utilization, NCCD-related health expenditures and distances to health care providers were compared by sex and by wealth quintile, and a Heckman regression model was used to estimate health expenditures taking selection bias in health care utilization into account. RESULTS: The prevalence of NCCDs in our sample was 6.2%. NCCD-affected individuals from the wealthiest quintile utilized formal health care nearly twice as often as those from the lowest quintile (87.8% vs 46.2%, p = 0.002). Women reported foregone formal care more often than men (43.5% vs. 27.0%, p = 0.058). Health expenditures relative to annual consumption of the poorest quintile exceeded those of the highest quintile 2.2-fold, and the poorest quintile exhibited a higher rate of catastrophic health spending (10.8% among NCCD-affected households) than the three upper quintiles (4.2% to 6.7%). Long travel distances to the nearest provider, highest for the poorest quintile, were a significant deterrent to seeking care. Using distance to the nearest facility as instrument to account for selection into health care utilization, we estimated out-of-pocket health care expenditures for NCCDs to be significantly higher in the lowest wealth quintile compared to the three upper quintiles. CONCLUSIONS: Facing potentially high health care costs and poor accessibility of health care facilities, many individuals suffering from NCCDs-particularly women and the poor-forego formal care, thereby increasing the risk of more severe illness in the future. When seeking care, the poor spend less on treatment than the rich, suggestive of lower quality care, while their expenditures represent a higher share of their annual household consumption. This calls for targeted interventions that enhance health care accessibility and provide financial protection from the consequences of NCCDs, especially for vulnerable populations.

Sustained effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: A population-based study.

BACKGROUND: Hypertension is a leading risk factor for death in sub-Saharan Africa. Quality treatment is often not available nor affordable. We assessed the effect of a voluntary health insurance program, including quality improvement of healthcare facilities, on blood pressure (BP) in hypertensive adults in rural Nigeria. METHODS: We compared changes in outcomes from baseline (2009) to midline (2011) and endline (2013) between non-pregnant hypertensive adults in the insurance program area (PA) and a control area (CA), through household surveys. The primary outcome was the difference between the PA and CA in change in BP, using difference-in-differences analysis. RESULTS: Of 1500 eligible households, 1450 (96.7%) participated, including 559 (20.8%) hypertensive individuals, of which 332 (59.4%) had follow-up data. Insurance coverage increased from 0% at baseline to 41.8% at endline in the PA and remained under 1% in the CA. The PA showed a 4.97 mm Hg (95% CI: -0.76 to +10.71 mm Hg) greater decrease in systolic BP and a 1.81 mm Hg (-1.06 to +4.68 mm Hg) greater decrease in diastolic BP from baseline to endline compared to the CA. Respondents with stage 2 hypertension showed an 11.43 mm Hg (95% CI: 1.62 to 21.23 mm Hg) greater reduction in systolic BP and 3.15 mm Hg (-1.22 to +7.53 mm Hg) greater reduction in diastolic BP in the PA compared to the CA. Attrition did not affect the results. CONCLUSION: Access to improved quality healthcare through an insurance program in rural Nigeria was associated with a significant longer-term reduction in systolic BP in subjects with moderate or severe hypertension.

Costs and Cost-Effectiveness of Hypertension Screening and Treatment in Adults with Hypertension in Rural Nigeria in the Context of a Health Insurance Program.

BACKGROUND: High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria. METHODS: A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario. RESULTS: Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment. CONCLUSIONS: Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.

Costs of cardiovascular disease prevention care and scenarios for cost saving: a micro-costing study from rural Nigeria.

OBJECTIVE: To assess the costs of cardiovascular disease (CVD) prevention care according to international guidelines, in a primary healthcare clinic in rural Nigeria, participating in a health insurance programme. METHODS: A micro-costing study was conducted from a healthcare provider perspective. Activities per patient per year (e.g., consultations, diagnostic tests) were based on clinical practice in the study clinic. Direct (e.g., staff, drugs) and indirect cost items (overheads) for each activity were measured. A cohort study, patient and staff observations, and interviews in the study clinic provided patient resource utilization data. Univariate sensitivity analyses were performed. Scenario analyses evaluated cost-saving options. The main outcome was the costs of CVD prevention care per patient per year. RESULTS: The costs of CVD prevention care were United States dollars (USD) 144 (range 130-158) per patient per year. Direct costs were USD 82 and indirect costs were USD 62. The main cost drivers were drugs (USD 39) and diagnostic tests (USD 36). The costs of hypertension care were USD 118 (107-132) and that of diabetes care USD 263 (236-289) per patient per year. A combination of task-shifting from doctors to nurses, reduction of appointment frequencies, and minimal organ damage screening would result in a direct cost reduction of 42%. CONCLUSION: This is the first study to report the costs of CVD prevention care in sub-Saharan Africa, based on prospectively collected operational data. The costs observed in our study are unaffordable in many countries in sub-Saharan Africa, highlighting the need for innovative financing mechanisms to fund CVD prevention care.

Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria.

BACKGROUND: While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria. METHODS AND FINDINGS: We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program's scale up within the State's healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9-152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program's scale up by the State is dependent on further investments in healthcare. CONCLUSIONS: This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care.

Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria: an operational cohort study.

OBJECTIVE: To assess the feasibility of providing guideline-based cardiovascular disease (CVD) prevention care within the context of a community-based health insurance program (CBHI) in rural Nigeria. METHODS: A prospective operational cohort study was conducted in a primary healthcare clinic in rural Nigeria, participating in a CBHI program. The insurance program provided access to care and improved the quality of the clinics participating in the program, including CVD prevention guideline implementation. Insured adults at risk of CVD were consecutively included upon clinic attendance. The primary outcome was quality of care determined by scoring of quality indicators on patient files of the cohort, 1.5 year after guideline implementation. RESULTS: Of the 368 screened patients, 349 were included and 323 (93%) completed 1 year of follow-up. The majority of patients (331, 95%) had hypertension. Process indicators showed that 114/115 (99%) new hypertension cases had a record of CVD risk assessment and 249/333 (75%) eligible cases a record of lifestyle advice. Outcome indicators showed that in 292/328 (64%) hypertension cases, blood pressure was on target. Barriers to care included limited human resources, limited affordability of diagnostic tests and multidrug regimes for the healthcare provider, frequent doctor's appointments, and inefficient drug supplies. CONCLUSION: Implementation of CVD prevention care within the context of a CBHI program resulted in high-quality care in rural sub-Saharan Africa, comparable to high-income countries. However, guideline implementation was resource-intense and specific recommendations were not feasible. Simple models of care delivery are needed for rapid scale-up of CVD prevention services in sub-Saharan Africa.

Target organ damage among hypertensive adults in rural Nigeria: a cross-sectional study.

OBJECTIVES: To study the prevalence of target organ damage (TOD) in hypertensive adults in a general population in rural Nigeria, to assess determinants of TOD and the contribution of TOD screening to assess eligibility for antihypertensive treatment. METHODS: All adults diagnosed with hypertension (n=387) and a random sample (n=540) out of all nonhypertensive adults, classified during a household survey in 2009, had a blood pressure measurement and were invited for TOD (myocardial infarction, left ventricular hypertrophy, angina pectoris, kidney disease) screening in 2011. RESULTS: Participation in TOD screening was 51% (n=196) in respondents with hypertension and 33% (n=179) in those without hypertension. TOD prevalence in hypertensive and nonhypertensive adults was 32 and 15%, respectively. Hypertension severity was a strong determinant for TOD [grade 1 odds ratio (OR) 2.66, 95% confidence interval (CI)1.04-6.84; grade 2 OR 3.82, 95% CI 1.41-10.36]. Out of 196 hypertensive patients, 151 were untreated, of whom all grade 2 hypertensive patients (n=71) were eligible for treatment. Screening revealed TOD in 19 out of 80 grade 1 hypertensive respondents (24%), therefore also classifying them as eligible for treatment. TOD screening hypertensive nonrespondents had more severe hypertension than hypertensive respondents, which may have resulted in an underestimation of the true prevalence of TOD among adults with hypertension. CONCLUSION: A high prevalence of 32% TOD in hypertensive adults in rural Nigeria was observed. Almost a quarter of respondents with grade 1 hypertension were eligible for antihypertensive treatment based on TOD screening findings. As TOD screening is mostly unavailable in sub-Saharan Africa, we propose antihypertensive treatment for all patients with hypertension.

Step-by-step guideline for disease-specific costing studies in low- and middle-income countries: a mixed methodology.

BACKGROUND: Disease-specific costing studies can be used as input into cost-effectiveness analyses and provide important information for efficient resource allocation. However, limited data availability and limited expertise constrain such studies in low- and middle-income countries (LMICs). OBJECTIVE: To describe a step-by-step guideline for conducting disease-specific costing studies in LMICs where data availability is limited and to illustrate how the guideline was applied in a costing study of cardiovascular disease prevention care in rural Nigeria. DESIGN: The step-by-step guideline provides practical recommendations on methods and data requirements for six sequential steps: 1) definition of the study perspective, 2) characterization of the unit of analysis, 3) identification of cost items, 4) measurement of cost items, 5) valuation of cost items, and 6) uncertainty analyses.Please provide the significance of asterisk given in table body. RESULTS: We discuss the necessary tradeoffs between the accuracy of estimates and data availability constraints at each step and illustrate how a mixed methodology of accurate bottom-up micro-costing and more feasible approaches can be used to make optimal use of all available data. An illustrative example from Nigeria is provided. CONCLUSIONS: An innovative, user-friendly guideline for disease-specific costing in LMICs is presented, using a mixed methodology to account for limited data availability. The illustrative example showed that the step-by-step guideline can be used by healthcare professionals in LMICs to conduct feasible and accurate disease-specific cost analyses.

Effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: a population-based study.

IMPORTANCE Hypertension is a major public health problem in sub-Saharan Africa, but the lack of affordable treatment and the poor quality of health care compromise antihypertensive treatment coverage and outcomes. OBJECTIVE To report the effect of a community-based health insurance (CBHI) program on blood pressure in adults with hypertension in rural Nigeria. DESIGN, SETTING, AND PARTICIPANTS We compared changes in outcomes from baseline (2009) between the CBHI program area and a control area in 2011 through consecutive household surveys. Households were selected from a stratified random sample of geographic areas. Among 3023 community-dwelling adults, all nonpregnant adults (aged ≥18 years) with hypertension at baseline were eligible for this study. INTERVENTION Voluntary CBHI covering primary and secondary health care and quality improvement of health care facilities. MAIN OUTCOMES AND MEASURES The difference in change in blood pressure from baseline between the program and the control areas in 2011, which was estimated using difference-in-differences regression analysis. RESULTS Of 1500 eligible households, 1450 (96.7%) participated, including 564 adults with hypertension at baseline (313 in the program area and 251 in the control area). Longitudinal data were available for 413 adults (73.2%) (237 in the program area and 176 in the control area). Baseline blood pressure in respondents with hypertension who had incomplete data did not differ between areas. Insurance coverage in the hypertensive population increased from 0% to 40.1% in the program area (n = 237) and remained less than 1% in the control area (n = 176) from 2009 to 2011. Systolic blood pressure decreased by 10.41 (95% CI, -13.28 to -7.54) mm Hg in the program area, constituting a 5.24 (-9.46 to -1.02)-mm Hg greater reduction compared with the control area (P = .02), where systolic blood pressure decreased by 5.17 (-8.29 to -2.05) mm Hg. Diastolic blood pressure decreased by 4.27 (95% CI, -5.74 to -2.80) mm Hg in the program area, a 2.16 (-4.27 to -0.05)-mm Hg greater reduction compared with the control area, where diastolic blood pressure decreased by 2.11 (-3.80 to -0.42) mm Hg (P = .04). CONCLUSIONS AND RELEVANCE Increased access to and improved quality of health care through a CBHI program was associated with a significant decrease in blood pressure in a hypertensive population in rural Nigeria. Community-based health insurance programs should be included in strategies to combat cardiovascular disease in sub-Saharan Africa.

Hypertension in sub-Saharan Africa: cross-sectional surveys in four rural and urban communities.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of adult mortality in low-income countries but data on the prevalence of cardiovascular risk factors such as hypertension are scarce, especially in sub-Saharan Africa (SSA). This study aims to assess the prevalence of hypertension and determinants of blood pressure in four SSA populations in rural Nigeria and Kenya, and urban Namibia and Tanzania. METHODS AND FINDINGS: We performed four cross-sectional household surveys in Kwara State, Nigeria; Nandi district, Kenya; Dar es Salaam, Tanzania and Greater Windhoek, Namibia, between 2009-2011. Representative population-based samples were drawn in Nigeria and Namibia. The Kenya and Tanzania study populations consisted of specific target groups. Within a final sample size of 5,500 households, 9,857 non-pregnant adults were eligible for analysis on hypertension. Of those, 7,568 respondents ≥ 18 years were included. The primary outcome measure was the prevalence of hypertension in each of the populations under study. The age-standardized prevalence of hypertension was 19.3% (95%CI:17.3-21.3) in rural Nigeria, 21.4% (19.8-23.0) in rural Kenya, 23.7% (21.3-26.2) in urban Tanzania, and 38.0% (35.9-40.1) in urban Namibia. In individuals with hypertension, the proportion of grade 2 (≥ 160/100 mmHg) or grade 3 hypertension (≥ 180/110 mmHg) ranged from 29.2% (Namibia) to 43.3% (Nigeria). Control of hypertension ranged from 2.6% in Kenya to 17.8% in Namibia. Obesity prevalence (BMI ≥ 30) ranged from 6.1% (Nigeria) to 17.4% (Tanzania) and together with age and gender, BMI independently predicted blood pressure level in all study populations. Diabetes prevalence ranged from 2.1% (Namibia) to 3.7% (Tanzania). CONCLUSION: Hypertension was the most frequently observed risk factor for CVD in both urban and rural communities in SSA and will contribute to the growing burden of CVD in SSA. Low levels of control of hypertension are alarming. Strengthening of health care systems in SSA to contain the emerging epidemic of CVD is urgently needed.

Psychological and social adjustment to blindness: understanding from two groups of blind people in Ilorin, Nigeria.

BACKGROUND: Blindness can cause psychosocial distress leading to maladjustment if not mitigated. Maladjustment is a secondary burden that further reduces quality of life of the blind. Adjustment is often personalized and depends on nature and quality of prevailing psychosocial support and rehabilitation opportunities. This study was aimed at identifying the pattern of psychosocial adjustment in a group of relatively secluded and under-reached totally blind people in Ilorin, thus sensitizing eye doctors to psychosocial morbidity and care in the blind. MATERIALS AND METHODS: A cross-sectional descriptive study using 20-item Self-Reporting Questionnaire (SRQ) and a pro forma designed by the authors to assess the psychosocial problems and risk factors in some blind people in Ilorin metropolis. RESULT: The study revealed that most of the blind people were reasonably adjusted in key areas of social interaction, marriage, and family. Majority were considered to be poorly adjusted in the areas of education, vocational training, employment, and mobility. Many were also considered to be psychologically maladjusted based on the high rate of probable psychological disorder of 51%, as determined by SRQ. Factors identified as risk factors of probable psychological disorder were poor educational background and the presence of another medical disorder. CONCLUSION: Most of the blind had no access to formal education or rehabilitation system, which may have contributed to their maladjustment in the domains identified. Although their prevailing psychosocial situation would have been better prevented yet, real opportunity still exists to help this group of people in the area of social and physical rehabilitation, meeting medical needs, preventive psychiatry, preventive ophthalmology, and community health. This will require the joint efforts of medical community, government and nongovernment organizations to provide the framework for delivery of these services directly to the communities.

Psychosocial characteristics of totally blind people in a nigerian city.

PURPOSE: To characterize the demographic and psychosocial problems of a group of blind people as a way of attracting more attention to and providing data that can improve the psychosocial care of the visually impaired. MATERIALS AND METHOD: A cross-sectional descriptive study of a population of totally blind people in Ilorin, Nigeria using a self-report questionnaire (SRQ). The questionnaire was verbally administered by the study personnel in the local language. Simple frequency tables were obtained and the Chi-square test was performed to determine significant differences between variables. P value <0.05 was considered statistically significant. RESULTS: Sixty one blind patients consented to participate. Most participants were engaged in street begging for their livelihood. Most subjects desired a job change, signifying dissatisfaction with the present occupation. Up to 80% of the cohort was married and had spouses who were also blind in at least one eye. Approximately two-thirds had five or more children and majority lived with family members who were responsible for taking care of their personal hygiene, cooking and mobility. The majority developed blindness in childhood and 16% had a family history of blindness and 77% had never used conventional eye care, with corneal disease being the most frequent cause of blindness. Many feared that their children may also become blind. Thirty-one (51%) scored ≥5 on SRQ and were classified as probable cases of psychological disorder. CONCLUSION: Blindness in a majority of cases that started in childhood was probably preventable. Inaccessibility to or failure of the formal rehabilitation and social welfare systems may have caused this psychosocial dilemma. The high level of social and family interaction provides opportunity for organized preventive ophthalmology, community health care services and psychosocial care.