Utilization of primary health care facilities in Lagun Community of Lagelu Local Government Area of Oyo State Nigeria

Utilization primary care ABSTRACT Poor funding and mismanagement were identified as a major setback to healthcare service delivery in Nigeria and of which is a prominent factor affecting its coverage and quality. This study examined the gap in the utilization of primary healthcare facilities in Lagun Community of Lagelu Local Government Area of Oyo State Nigeria. A cross-sectional study design using multi-stage random sampling technique to select 80 respondents that met the criteria were given the opportunity to participate in the study. A semi-structured questionnaire was used to collect information from respondents. Descriptive statistics and Chi-square were used for data analysis at 0.05 significance level, results showed that mean age of respondents was 30.5±17.0, where majority (97.4%) speaking indigenous Yoruba language. More than half (56.2%) were Christians, 56.6% had secondary education, and two-fifth (40.0%) of respondents being traders. Relationship between utilization and other factors at (X 2 =1.000, df=1, p=0.183) showed that awareness and availability were good, while accessibility and affordability were below the expectation as recommended by World Health Organization. Also, utilization of facilities that embraced health-for-all projected for the year 2020 millennium development goal would have assisted better improvement in achieving an holistic medical architecture through government and other health agencies proactive approaches if more enlightenment, intervention, health insurance accessibility, unalloyed cooperation of the dwellers with various health professionals anticipating in promoting utilization of health facilities in the community.


INTRODUCTION
Utilization of primary healthcare (PHC) is a pivotal to health living standard of the rural community like Lagun in Lagelu Local Government Area (LGA) of Oyo State Nigeria (WHO, 1978). Although, this stands as the focus point of the study and which should attest to the community's awareness, accessibility, availability and affordability of its dwellers benefits as to their perceptions and patterns of use of all the existing facilities toward the improvement of healthcare services respective demand and supply. Although, there was dart of information to the study and this prompted the researcher to develop the passion to assess the utilization of PHC facilities in this community and which stood as the aim and scope of this study.
According to World Health Organization (WHO) (1946), health is defined as a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity. Inherent in this fact, was the ability to adapt and manage physical, mental and social challenges throughout life existence by the willing all and sundry (Huber et al, 2011). However, activities to prevent or cure health examined and diagnosed medical problems, and to promote good health system to humans, have been undertaken by healthcare providers (WHO, 2015).
Obviously, PHC facility is the first place of consultation for all patients, which often utilize as a refuge by healthcare services consumers either in urban or rural community in any perfectly functioning healthcare system globally, and which is as a consequence of health seeking behavior of individuals at such community. Altogether, this might be affected by several factors, e.g., socio-economic, political, religious, educational, socio-cultural, etc. And these factors are not in variance in Lagun Community of the LGA. Holistically, healthcare centers are community based and patients directed organizations that deliver comprehensive, culturally competence, high quality PHC services (Robert et al., 2018).

Statement of the Problem
Though, it is not enough for the service to be available, but utilization is most paramount, as patients may choose not to use the available healthcare services. The decision to utilize available health services depend fully on peoples' choice and perception about services, accessibility, availability and affordability of the healthcare services in their domain. And the decision of the people depends on their perception and judgment conditioned to factors, such as tradition and culture also perceived competence of the health staff, attentiveness and responsiveness. Also, discovered that religion, cost of healthcare service, distance to facilities, waiting time and quality of care were non-utilization of healthcare facilities. Poor utilization of healthcare facilities as well being propelled by poverty and level of education before, during and after delivery by pregnant and nursing mothers are the major cause of disease burden in children.
Health surveys conducted in 2008 in Nigeria revealed that majority of people in the country have no health insurance coverage to cater for their bills (National Population Commission, 2013). This simply suggests that majority of the people have to pay out of pocket making health utilization dependent on socio-economic status. However, despite the efforts of the partnership with the private sector to promote improved access to quality maternal health service, individuals still lagged behind in the utilization of these opportunities (Federal Republic of Nigeria, 2010). This means that the huge global and national investment aimed at effective healthcare delivery has not yielded the desired results because of poor utilization and ultimately low access. Gaps have also been made clear between individuals need and actual access to critical health services (National Population Commission, 2013).
The pattern of the utilization of available facilities, type of services being provided in those facilities and effectiveness of healthcare workers assigned to render those needed service at Lagun Community and its environs in Lagelu LGA of Oyo State Nigeria are yet to be explored and this is the gap to be addressed in the study.

Justification of the Study
The study has potential for yielding information relating to the facilitating factors, which influence the pattern of utilization of healthcare services provided at facilities in Lagun Community and its environs. Awareness about the present facilities were carried out, therefore, used for re-designing and providing services that were sensitive to the needs and sociocultural beliefs the populace. The result of the study was useful for designing or modifying the health planning and policy for PHC services provided at the Lagun healthcare facilities and others. It was exposed that facilities challenges affecting the utilization and health seeking behavior of the community healthcare services, policy formulations and implementation by the three tiers of government and other healthcare managers of these challenges to new effective and efficient ways of handling them. In addition, the result of the study would be useful for designing or modifying basic WHO standards for PHC at the community level and which would also help to promoting community sensitive programs and in planning public enlightenment program to increase uptake and utilization of these present facility for adequate healthcare services provided at the Lagun healthcare facilities. The challenges affecting the utilization would help to provide policy formulations and implementation for management with a new effective and efficient mechanism. The result of the study would as well assists in ascertaining validated and valuable information in carrying out meaningful training, implementation, evaluation and review of healthcare facility administration general.

Study Area
This study was carried out in Lagun Community of Lagelu LGA of Ibadan in Oyo State. The local government has a projected estimated population of 167,828 in 2010 compared with total population of 148,133, which made up of adolescents' population of 34,161 and location of 7 0 31 ` 60"N, 4 0 6 ` 0"E according to the 2006 census. It has a land mass of 310,850 square kilometers (National Population Commission, 2013), with occupations predominantly of agricultural practices and trading. Altogether, Lagun General Hospital, Lagun Primary Healthcare, and Abiola Victoria Ayoke (AVA) Health Compassion Initiative NGO facilities were present. Yoruba, Egede, and Igbo were the major ethnicity found therein. Lagun Community shared boundaries with Egbeda Local Government in the East and Iwo Local Government in Osun State in the West, Ibadan North Local Government in the North, and Akinyele Local Government and Ibadan North-East Local Government in the South.

Study Design
This study was a community-based descriptive cross sectional design which was carried out using interviewer administered questionnaire to assess the utilization of PHC facilities in Lagun Community of Lagelu LGA of Oyo State, which consisting of present dwelling people in Lagun and its environ communities, were adolescents, 10-19 years of age and adults of 19 years and above males and females, according to (WHO, 2015) that were residing therein, and in one way or the other had used, is using, will like to use and as well understood the importance of utilization of PHC facilities.

Sample Size Estimation
The sample size used for this study was 80, according to Leslie Kish formula for single proportion for community based cross sectional descriptive study with respect to the study design (Cochran, 1977). Therefore, this made the number of people that questionnaire was administered on in the study.

Study population and Sampling Technique
A purposive sampling technique was used to select participants out of the total population of that present inhabitants of Lagun and its environs, because of their preoccupations barrier, which was predominantly agricultural practices and trading, by those utilizing the Lagun General Hospital, Lagun Primary Healthcare, and AVA Health Compassion Initiative NGO facilities to be, 80 adults and adolescents of respondents in the study. Then, the statistical sampling technique used was multistage random and later purposively selected among those that were willing and available to participate in the study in-line with its ethical consideration.

Validity and Reliability
The instrument was subjected to face, content and construct validated and reliability using the relevant literatures, pilot test and subject experts in the field of healthcare service.

Data Collection Methods and Instrument
Data was collected within a week. Some of the questionnaires were retrieved just immediately after filling them, while others were waited for their collections, so as not to hinder the scheduled activities for participating respondents and missing of the questionnaires on transit.

Data Management and Analysis
Well filled and collated questionnaires with the help of two research assistants were collected and later hand-coded for data entering into the computer using IBM special package for social sciences version 20 software. Apart from sociodemographic characteristics and each of awareness, accessibility, availability and affordability were scored accurately and rated as poor, fair and good respectively. Data were analyzed using descriptive and inferential statistics using frequency-count, percentage, cross-tabulation, and Chisquare at 0.05 significance alpha level. Results were interpreted and presented using tables and formulated hypothesis were tested.

Ethical Considerations
Consent of the respondents were sorted, while the obliged community members were ethically and strongly encouraged to attend to all the questions with a high level of honesty and all sense of belonging in-line with the ethical principle guiding this study. The participants who did not consented were freely excused in order to observe the principle of good ethics in research conduct. Where respondents were then encouraged to give their very best of their experiences as to the PHC facilities utilization and invariably, identifiers such as names, phone number, addressed of the participants, etc. were not requested for. Participants completed opinions were kept confidential based on: right to decline/withdrawal from participating, beneficence to participants, non-maleficence (non-harmful) to participants' confidentiality. And data collected was assessed only by the researcher and data analyst for true findings of the study.

Socio-Demographic Characteristics of Respondents
The socio-demographic characteristics of respondents, as shown in Table 1. A few above half of respondents, 41 representing majority (51.3%) of age groups, which were males. Age of respondents between ages less than twenty years (<20 years) and ages between 20-29 years had the highest of 24 representing 30.0% of the respondents. Indigenous Yoruba language (78) representing 97.4% topped the list of ethnic groups that participated in the study. Few above half, 45, which were majority representing 56.2% proportion of respondents, were Christians. Though, few above half of the respondents, 47 representing 56.6%, had secondary education. Also, a few below half, 39 representing 48.7% of respondents, were married. Few,19 representing 23.8%, were farmer, while two-fifth respondents, 32 representing 40.0%, were traders. Altogether, 24 representing 30%, earned N20,000 and above, while a few above one-quarter, 28 representing 32.5%, had between N1,000 and N4,999, which championed the peoples' monthly income of the respondents that participated in the study (see Table 1).

Level of Awareness of the Healthcare Facilities of Respondents
The level of awareness for the utilization of healthcare facilities was high among respondents with the majority of the respondents, 68 representing 85.0%, claimed "yes" to have heard about the existence of healthcare facilities in Lagun Community. It was confirmed that a little below two-fifth, 33 representing 41.2% of respondents, said neither healthcare workers nor their people made them had about the healthcare facilities in the community, while few below two-fifth, 32 representing 40.0%, agreed that either health workers or their people that made them know the presence of health facilities in the community. A little above half, 42 representing 52.5% of respondents, revealed "no" to the health facilities provision of poor healthcare services to the people of the community, while a few above one-third, 29 representing 36.2%, answered "yes" to the same question. Majority of respondents, 59 representing 73.8%, said "yes" to the ownership of the facilities to be government. Also, a little above half, 46 representing 57.5%, confirmed that the facilities have the capacity to attend to all their illnesses situations ( Table 2).

Availability of Healthcare Facilities of Respondents
Almost all, 69 representing 86.2% of respondents, said they knew where the healthcare facilities were situated in Lagun Community. Also, majority of respondents, 49 representing 61.2%, testified to the fact that the healthcare centers were not meant for only the rich people or averagely capable people among them but everyone in Lagun Community. Majority, 53 representing 68.2% of respondents, said that the facilities were not too far away from their houses i.e. its trekable while a few below one-third, 24 representing 30.0%, said not. Almost all, 57 representing 71.2% of respondents, said "yes" to healthcare facilities were meant to diagnose, prescribe, treat, and taking good care of series of health challenges of the people in the community. Majority, 54 representing 67.5% of respondents, recorded "yes" to the health facilities opened ( Table 3).

Accessibility of the Healthcare Facilities of Respondents
About 10 of the respondents (12.5%) reported they did not had accessibility to some of the roads that links to the healthcare facility while majority, 69 representing 86.2%, expressed that all roads are trekable. A little, 10 representing 12.5% of respondents, declared that one cannot go to the Lagun Community facilities to receive healthcare service while almost all, 65 representing 81.3% respondents, consented that one can proceed to the facilities to receive healthcare service. Although, few above two-fifth, 31 representing 38.8% of respondents, reported that attendance and admission for  services in the health facilities are too rigorous and while a few above half of the respondents, 42 representing 52.4%, attested that they were not so. More so, little, 19 representing 23.7% of respondents, said it will be up to two hours before getting to the facilities before being attended to while majority, 54 representing 67.5%, otherwise said no to such. Altogether, few, nine representing 11.2% of respondents, declined that they had never heard or noticed of anybody sometime gone to the health facilities for medical attention while almost all, 66 representing 82.5% of the respondents, openly confessed of being ever heard or noticed of such ( Table 4).

Affordability of the Healthcare Facilities of Respondents
A few below two-fifth, 32 representing 40.0% of respondents, indeed paid for the registration for medical services attendance in the health facilities while a few below half of the respondents, 39 representing 48.8%, indeed said they paid for the registration for the medical services attendance in the health facilities. A little respondent, 14 representing 17.5%, testified to the payment for the servicecharge services in the facilities that they were very cheap and friendly while majority of respondents, 60 representing 75%, said there were service-charge for the facilities but very cheap and friendly. Also, exactly half of respondents, 40 representing 50%, said it was the government that levied them highly for every health service received in the health center while little below a quarter of respondents, 19 representing 23.8%, were not in concord with the fact that it was the government that levied them for every health service received in the health center.
A few below two-fifth respondents, 32 representing 40% said "yes" that the healthcare provider in the center were over billing or exploiting them on every healthcare service that is being undertaken in the facilities while a few about two-fifth of respondents, 34 representing 42.5%, confirmed no to the statement to the center over billing or exploitation on every health service undertaken in the facilities. Although, a few below one-third of respondents, 26 representing 32.5%, confessed "no" that their allocation from their total budgeted income for their family anticipated health service-charge while many of the respondents, 46 representing 57.5%, confirmed "yes" that their allocated income from their budgeted income could cover the family anticipated health service-charge ( Table 5).

Utilization of the Health Care Facilities of Respondents
Almost all, 62 representing 77.5% of respondents, said that they had used or just starting to use or will like to use these health care facilities in future. A few above half, 43 representing 53.7%, consented to the scope of operation and equipment on ground were not cable of meeting the health services demand of the people in the community i.e. not reliable to depend on. Though, a little above two-fifth, 33 representing 41.3% of respondents, contradicted "no" that the facilities were meant to diagnosis, drug prescribe, treat and take good health care of series of health challenges for promoting physical, social, emotional, etc. for the old, young, pregnant, nursing mothers, children, and others living in Lagun Community while few below two-fifth, 31 representing 38.7% respondents, supported the establishment of the facilities for such in the community. Although, a little above two-fifth, 33 representing 41.3%, responded "no" to the functionability of those facilities in the last a year or there  about as to requesting for medical service for themselves, while a few below two-fifth, 31 representing 38.7%, responded "yes" to the functionability of those facilities. Altogether, a few below two-fifth, 31 representing 35.0%, said "yes" to the fact that health care workers in the facilities were not capable, too wicked, and not accommodative to their patients, while a few above two-fifth, 33 representing 41.3%, confessed "no" to the statement ( Table 6). Table 7 shows the statistical descriptive summary of the healthcare facilities factors. Table 8 shows the cross-tabulation of utilization score with respondents' awareness score of healthcare facilities. Little above one-quarter of the respondents, 7.8 representing 26.1%, and few below three-quarter, 15.2 representing 73.9% of the respondents, had bad awareness or were not aware about the facilities (not utilizing facilities), while a few below onethird, 12.5 representing 32.4%, and a few above two-third, 24.5 representing 67.6% of the respondents, had good awareness with good utilization of health facilities, respectively. Though, p-value of 0.05 or the standards to measure the level of significance using Chi-square test statistics at X 2 =1.000, df=1, and p=0.257. Table 9 shows the cross-tabulation of utilization score with respondents' availability score of healthcare facilities. A little below one-third of the respondents, 7.4 representing 31.8%, and a few above two-third, 14.6 representing 68.2% of the respondents, had bad availability about facilities or not utilizing facilities, while a few above one-third, 19.6 representing 34.5%, and a few below two-third, 38.4 representing 65.5% of the respondents, had facilities availability with good utilization of health facilities, respectively. Though, p-value of 0.05 or the standards to measure the level of significance using Chi-square test at X 2 =1.000, df=1, and p=0.521. Table 10 shows the cross-tabulation of utilization score with respondents' accessibility score of healthcare facilities. Majority, three-quarter of the respondents, 24.0 representing 75.0%, and one-quarter, 8.0 representing 25.0% of the respondents, had bad accessibility about facilities or not utilizing facilities, while few below one-third, 23.0 representing 26.5%, and few above two-third, 45.1 representing 73.5% of the respondents, had accessibility with good utilization of health facilities respectively. Though, pvalue of 0.05 or the standards to measure the level of significance using Chi-square test statistics at X 2 =1.000, df=1, and p=0.265.   Table 11 shows the cross-tabulation of utilization score with respondents' affordability score of healthcare facilities. A few above one-third of the respondents, 14.5 representing 34.9%, and a few above two-third, 28.5 representing 65.1% of the respondents, had bad affordability, that is cannot afford the facilities and bad utilization and thus not utilize the facilities, respectively, while a few below one-third, 12.5 representing 32.4%, and a few above two-third, 24.5 representing 67.6% of the respondents, had affordability, that is, can afford the healthcare facilities and good utilization or they were utilizing the health facilities, respectively. Though, p-value of 0.05 or the standards to measure the level of significance using Chi-square test statistics at X 2 =1.000, df=1, and p=0.183.

DISCUSSION
Though, possible reasons while the health facilities in the community were not being utilized, as against the observed usual low turn-out of the community dwellers, which was against its primary conception for salvaging and better all possible ill-health status of the people which was in support (Hassan et al., 2016).
Although, poor health services affordability, inadequate proper awareness for all the relevant, necessity, and importance of health interventional orientations saddled with their low state of poor educational exposure, culture and religion ethics, traditional beliefs background to the adequacy of western medical facility regimentation in-line with deplorable competency of breeds of health personnel with unaffordable service charges in the locality facilities as against finding by Asakitikpi (2019), for quality health service delivery and others cumulated factors best known to the people possibly resulted to the poor performance utilization gaps that this study was designed and researched on, which is, as against the WHO declaration standards for the vision of health-for-all by the year 2020.
Although, the findings from the study revealed some vibrant issues, which called for a holistic general over-hauling of all the present medical architecture by all health stakeholders to bring all resources together for a re-designing the existing health policies and programs for true PHC advocacy values from all facilities in Lagun Community together with all other communities for safe medical delivery as opined by Uzochukwu et al. (2015) in order to actualize the best global health practices as to healthy policies formulation and implementation by the competent and seasoned health professional at all times.
The results of hypotheses finding were not significant, where p-value at 0.05 significant level when the hypotheses were rejected, because there was not statistically significant relationship between healthcare facilities utilization against awareness, availability, accessibility and affordability of respondents respectively. Using Chi-square for their statistical test to establish the respective relationship against utilization, they were confirmed that few above half of the respondents of the community were not comfortable with accessibility and affordability or could not access and affordable service charges being leveled against them irrespective of the good awareness and availability of healthcare facilities by above half of respondents in the community. However, these confirmed that, those ones that were vulnerable to respective lowincomes and as a result, many households in the community experience slight above average health facilities utilization due to poverty, as opined by Khan et al. (2017) and Mahumud et al. (2018). These findings needed to be improved on, because they were not up to the standard expected by the WHO, which recommended that all United Nation members should step-up for achieving universal health coverage (UHC) fully by 2030, as a part of the recent sustainable development goals (SDGs) and that, half of the world's population are still unable to obtain essential health services (MOHFW, 2015;UHC, 2017), which says "all individuals and communities who need health services should receive them without suffering financial hardship".

CONCLUSIONS AND RECOMMENDATIONS
A timely, adequate communication, and good commitment by the national, state and local government health management and managers for healthcare facility is to be delivered by the competent health professionals, and these would salvage the health service utilization by inhabitants of the community via their healthcare facilities, to prevent, promote, protect, preserve and rehabilitate to offer a dynamic global best healthcare practices as to awareness, availability, accessibility, affordability respectively for a timely, perfectly and safe utilization of all facilities in the Lagun Community for all.
These are for nothing, but for patients' satisfaction, as an important indicator for measuring quality healthcare service with adequate health recording and conventional data accessible information with time-to-time upgrading of safe healthcare equipment for implementation of the global healthcare best practices policies etc. If all these and others were not met to achieving healthcare emergencies coverage in such community, invariably, such could jeopardize community healthy living.
The following were recommended on the utilization of Primary Health Care Facilities in Lagun Community of Lagelu Local Government Area of Oyo State Nigeria: 1. Community people should come together to form association so as to key into health insurance scheme in-line with the government cheap health regulation policy, to ease burden that is attributed to the affordability of using healthcare facilities for service delivery.
2. People of the community are to cooperate without violence and provoking all categories of health professionals against prevention and control of both infectious and communicable diseases together with other accidental health challenges in the community and motivated to use community healthcare facilities.
3. Health advocacy and interventions as to health trainings, preventions, promotion and rehabilitation should be extended to the people of the community with constant health team workers should be mandatory on ground for tangible health service delivery to the people of the community.
4. Foreign agencies, international communities and nongovernment organizations should intensify efforts as well as their capacity in making a healthy global projected goal(s) realisable by powering such at a developing country grass-root like Lagun Community in Lagalu LGA of Oyo State in Nigeria as to the health developmental differential and for dwellers to holistically enjoy the basic health as programmed.