Economic Burden of Inpatient Wound Dressing in Nigeria: Implication for Catastrophic Household Expenditure

Background: The literature is replete with family impoverishment resulting from out of pocket healthcare �nancing on the Africa continent. In Nigeria the healthcare insurance scheme is evolving and requires wider coverage. The aim of this study is to examine catastrophic household expenditure emanating from daily or alternate day wound dressing. Methods. The study was based on a descriptive cross-sectional research design to investigate the economic burden of daily or alternate day wound dressing among hospitalized patients in selected teaching hospitals in south west Nigeria. The inclusion criteria focused on inpatients about to be discharged or already spent minimum of four weeks in hospital. The data collection instrument was pre-tested with a coe�cient of stability of 0.774. Respondents were selected via convenience sampling while an interview administered questionnaire was used to elicit information on wound care from patients in medical surgical wards. Covid-19 protocols were strictly adhered to and ethical approval was sought from each hospital. Results: The result revealed that the mean age of the respondents was 44.95 ± 16.12. Two-thirds were men who are artisans and traders with only secondary school education. Over 70% of the respondents have between 5 and 10 family members, more than 50% earn less than ₦50000 per month. The majority have no comorbidities (79.5%), about 50% were on daily dressing which required 1–5 moderate or major dressing packs per week. The length of hospital stay for the majority of the respondents (85.3%) was less than 11 weeks. Conclusions: The daily or alternate day wound dressing requires a �nancial input beyond the coping capacity of the indigenous Nigerian families. The Nigerian government should scale up coverage of health insurance scheme to cover artisans, small traders and other low income earners to reduce the incidence of catastrophic household expenditure.


Introduction
Wound dressing is a major component of wound care protocol and requires high nursing intensity [1] . Daily or alternate day wound dressing places a huge nancial burden on the patients and health system and is likely to worsen in developing countries where resources are limited and health insurance coverage is inadequate [3][4][5][6][7][8] . For instance, in 2010, a study conducted in South Western Nigeria revealed that over 40% of the patients spent about ₦500 (1.35US$) on wound dressing alone per week [9] . This was period when in ation was checked and before Nigeria went into an economic recession. These days, the actual cost of wound dressing is expected to have increased in geometric ratio. Also, in the same study, the authors posited that over 70% of the patients are small traders and were unable to meet the nancial requirements of wound dressing. Nonetheless, studies in yore years have actually identi ed possible family impoverishment as a result of unending healthcare nances [6,10] Furthermore, in South Western Nigeria, a diabetic foot ulcers (DFU) study by Odusan, Amoran and Salami [11] revealed that 53% of the respondents earned less than ₦20,000 (54.13US$) per month, 34% earned between ₦20,000-₦49,000 (54.13US$-132.61US$) per month while no respondent earned more than ₦100,000 (270.63US$) per month. The result is similar to the ndings of Ogundeji et al [2] in the same geographical region of Nigeria which show that about 75% of the study respondents' monthly income was less than ₦50,000 (130.72US$) and yet they would be required to spend between ₦2000 (5.41US$) and ₦3000 (8.12US$) on wound dressing materials per week. This is a menace that have ravaged an array of developing nations. In Nigeria, government is scaling up strategies to improve access to health insurance scheme but the bene ts of the scheme are still largely for government workers and organized private sectors. In essence, inadequate access to medical care is by far causing perpetual disparities between the poor and the rich as the poor becomes poorer because of prolonged health care expenditure [3,12,13] Importantly, research evidence suggests that the high costs associated with wound management can be attributed to repeated dressing changes [14] . Builders and Oseni-Momodu's [15] [2] Consequently, in Nigeria, there is a paucity of data that specify the overall cost of inpatient wound dressings. Often when wound care cost are tracked, it is usually the cost of medical and surgical expenses while the huge care cost emanating from daily or alternate day wound dressing are neglected.
This creates a major drawback in establishing the actual nancial expenses incurred on wound dressing. This is a gap in most studies on wound care analysis and costing. Therefore, there is an urgent need for critical evaluation of the wound dressing cost component of wound management to improve data on the cost of wound dressing, budget and planning.

Material And Methods
The study was based on a descriptive cross-sectional research design to investigate the nancial implications of wound dressing among hospitalized patients in selected teaching hospitals in South Western Nigeria. The choice of the hospitals was based on their capacity to accommodate and manage large population of patients with wounds and also known to be a centre of excellence for practice, research and training. Study sites included all the medical/surgical wards where nurses engaged in wound dressing.
The inclusion criteria focused on inpatients about to be discharged or who already spent a minimum of four weeks in hospital. The data collection instrument was subjected to a test-retest reliability test and was found reliable with the coe cient of stability of 0.774. Data was collected from 190 patients across three teaching hospitals for a period of three months via an interview-administered questionnaire designed based on systematic literature review and the researchers' previous eld experience. The hospitals were selected through purposive sampling while the participants were selected through convenience sampling technique. Therefore, all in-patients with both acute and chronic wounds were recruited within the inclusion criteria. The data were collected during the covid-19 pandemic, therefore, precautionary measures of face masking, distancing and hand washing were strictly adhered to.
The collected data were entered into the Statistical Package for Social Sciences (SPSS) and analysed using descriptive and inferential statistics. The results were presented in percentages, mean and standard deviation. Ethical issues were considered from institutional to individual level; ethical clearance and permission were obtained from the Institutional Review Board (IRB) of each of the teaching hospitals: The National Orthopaedic Hospital, Igbobi, Lagos (OH/90/C/IX), the University of Ibadan/University College Hospital Ethical Committee (NHREC/05/01/2008a, 21/0047) and from the Obafemi Awolowo University Teaching Hospital Complex (ERC/2021/04/07). Verbal and written consent were also obtained from each of the participants while ethical principles of voluntariness, con dentiality, anonymity and nonmale cence were strictly upheld. ₦50,000 as a monthly income, 66(34.7%) of the respondents receive ₦50,000-₦100,000 as a monthly income, 6(3.2%) of the respondents receive ₦101,000-₦200,000 as a monthly income, 11(5.8%) of the respondents receive ₦151,000-₦200,000 as a monthly income and 6(3.2%) of the respondents receive more than ₦200,000 monthly.

Discussion Of Findings
The result generally shows that the working population within the age bracket thirty and younger than fty and dependent population who are sixty and older (table 1) are mostly patients who were hospitalized for various types of wound aetiologies ranging from road tra c accident, occupational injuries, traumatic injuries, pathological conditions including cancer related wounds (table 2). The study nding is similar to studies which reported a rising population of elderly for wound related care. The nding is consistent with a Nigerian study by Rahman et al in Ogundeji et al [2] which reported ages of sixty and older among patients hospitalized for wound related diagnoses.
From the results, two-thirds of the studied population were men (table 1) which is similar to Ogundeji et al [2] which reported over sixty per cent male respondents in a similar study in South Western Nigeria. This not surprising because certain high-risk jobs such as riding motorcycle, driving buses and cars for commercial purposes, factory work which may result into wound related injuries are reserved for males. Studies which examined the proportion of females in high risk jobs and the incidence of traumatic injuries are sparse. Notwithstanding, from the traditional African perspectives, men are expected to be the bread winners of their families. These individuals are the workforce who drives the economy of the country and provides for the need of their families. Therefore, they are mostly hospitalized for various types of wounds.
Findings also revealed that two-thirds of the patients were artisans and traders (Table 1) which make them more prone to occupational injuries and road tra c accidents. Artisans work with various sharp, blunt instruments while some are employed in companies using heavy duty machines and instruments. Similarly, small traders and hawkers form a signi cant percentage of Nigeria's economy and are found everywhere on the highways. This alone explains why road tra c accidents (34.2%) are the leading cause of wound related hospitalization. Government employment is not easy to get in Nigeria partly because of an overwhelming population of youth as well as systemic corruption and ethno-religion biases. South Western Nigeria, which is the study setting is an educationally developed geo-political zone of Nigeria. This is exempli ed in the result (table 1). From the ndings, two-thirds of the studied population have not less than secondary school education. This result is also consistent with Ogundeji et al [2] who reported over fty per cent tertiary education among the study respondents.
Signi cantly, ndings revealed that over fty per cent of the population studied earn less than ₦50,000 as salary (table 1) and over seventy per cent have more than 5 family members. This nding is similar to the ndings of Ogundeji et al [2] in the same geo-political region of Nigeria who reported that over seventy ve per cent of the respondents have more than 5 family members and earn less than ₦50,000 per month.
However, Odusan et al [11] in a study on cost of managing diabetic foot ulcers in South Western Nigeria reported a ₦20,000 salary for more than fty per cent of the respondents, which is lower than our nding. Also, more than fty per cent are on daily or alternate day wound dressing requiring 1-5 moderate or major dressing materials per week. The result is consistent with a similar study by Ogundeji et al [2] where more than eighty per cent of the patients were on daily wound dressing. The result is also in line with Builders and Oseni-Momodu's [15] ndings in Bingham University teaching hospital Jos Nigeria where about ninety per cent of the respondents were on alternate day wound dressing. Furthermore, ndings are also consistent with alternate day dressing in a study conducted by Odhiambo et al [16] in a County hospital in Kenya.
Furthermore, repeated dressing changes create a huge nancial commitment and has far-reaching effects on the family nances and therefore stretches the limit of the family wound care nancial coping capacity. Often, families use bizarre coping strategies such as substitution of payment for family basic needs such as dairy product for daily wound dressing. Some go further and sell household materials and investments to meet the huge economic demands of continuous wound dressing, which impoverishes the family. This nding con rmed a study in Bangladesh which concluded that the cost of healthcare affected the poor in the society the most and households spent about forty per cent of their income on healthcare nances. Furthermore, ndings are similar to the outcome of a study conducted by Oreh [10] and Aregbesola & Khan [6] where family impoverishment was associated with protracted healthcare expenses.
Again, ndings also revealed a surge in number of dependent citizens who are hospitalized for various types of wounds. About twenty per cent of the studied population were elderly (sixty-ve years and older). This study does not speci cally examine the types of wounds common among the elderly, however, it is known that malignancy and pathological conditions are common among the aged population. This nding concurs with Nussbaum [17] and Guest, Vowden &Vowden [18] who concluded that the increased cost of wound care among the elderly is associated with comorbidities such as diabetes and hypertension. Noteworthy is the increased number of cases of breast cancer (23%, table 2).
Breast cancer wounds are the second aetiological factor after road tra c accident wounds among hospitalized patients from study ndings. It follows that, as the population increases, the risk of fracture, pathological conditions and malignancy increases and it is consistent with the results of the study conducted by Cheng et al [14] and Narwade Saxena, Wasnik & Akhta [19] . Although two-thirds of the study population are without comorbidities, the length of stay for most hospitalized patients was about 11 weeks and they are on daily or alternate day dressing. This nding is also consistent with the ndings of Cheng et al [14] and Narwade et al [19] that an increase in the cost of wound care is related to an ageing population.
Also, most of the elderly people who are hospitalized were not enrolled in a health insurance scheme and were unable to nance their healthcare bill. It is disheartening that many of these elderly were forsaken in their old age and discharged against medical advice (DAMA) by their relatives because they could not meet the healthcare economic demands of the orthodox care settings. The Nigerian government has recently look into this direction by a bill to establish Senior Citizen Commission which is yet to be implemented. Payment strategies were poor and payment coping strategies include selling investments of many years such as landed property to settle catastrophic healthcare bills [20] . This phenomenon is supported by an argument by Karimo et al [12] , Ogundeji [13] and Aregbesola [3] that the poor in the society have become poorer because of prolonged healthcare expenditure.

Conclusion
The study examined the catastrophic household expenditure emanating from daily or alternate day wound dressing. The cost incurred from repeated dressing changes is beyond the coping capacity of the indigenous Nigerian families who are ultra-poor. The escalating cost of providing daily wound dressing materials and consumables in Nigerian hospitals cause catastrophic household expenditure which impoverish families. The literature is replete with family impoverishment resulting from out of pocket healthcare nancing on the African continent and the situation is not changing. From the study, the majority of cases were artisans, small traders and business people who earn less than fty thousand naira per month. The individual is not enrolled in a health insurance scheme and is therefore incapacitated to nance the cost of daily or alternate day wound dressing.

Declarations
Ethical Approval and Consent to participate Ethical issues were considered from institutional to individual level; ethical clearance and permission were obtained from the Institutional Review Board (IRB) of each of the teaching hospitals: The National Orthopaedic Hospital, Igbobi, Lagos (OH/90/C/IX), the University of Ibadan/University College Hospital Ethical Committee (NHREC/05/01/2008a, 21/0047) and from the Obafemi Awolowo University Teaching Hospital Complex (ERC/2021/04/07) all in Nigeria. Verbal and written consent were also obtained from each of the participant while ethical principles of voluntariness, con dentiality, anonymity and nonmale cence were strictly upheld.

Consent for publication
Not applicable Availability of data and materials Primary data was collected from hospitalized patients with wounds from the three hospitals in Nigeria.
The data was analyzed by the statistical package for Social Sciences (SPSS) and presented in frequency table, percentage, mean and standard deviation