Study objectives and theory of change
As public health practitioners and policy makers strive to achieve universal health coverage and optimize the use of primary healthcare services, this study was designed to investigate if female clients have gender preferences for frontline health workers who provide services to them within primary healthcare settings. Previous studies from Nigeria and other countries have not investigated gender-based preferences of patients/clients for frontline health workers working at primary healthcare level who provide maternal, newborn and child healthcare (MNCH) services nor have previous studies investigated the implications of gender-based preferences for the uptake of MNCH services at the primary healthcare level. This study is based on a theory of change which assumes that to achieve universal health coverage and improve health outcomes within health systems, the implementation frameworks of governments and other key stakeholders should increasingly take gender issues into consideration. Gender-based considerations are important as these may have implications for the willingness to access healthcare services and the uptake of maternal, newborn and child health services by patients and clients.
This research study was undertaken in two States (i.e. Bauchi and Cross River States) within Nigeria. Bauchi State is in the north-eastern part of the country with a predominantly Muslim population. Cross River State is in the southern part of Nigeria and has a predominantly Christian population. For Bauchi State, the rural Local Government Areas (LGAs) selected for the research study were Alkaleri and Giade LGAs while for Cross River State, the selected LGAs were Etung and Yala LGAs.
Study design and sampling procedure
The study was based on a cross-sectional quantitative research design. For site selection, multi-stage sampling was applied - the list of LGAs in Bauchi and Cross River States were stratified into urban and rural, which was followed by a random selection of two rural LGAs per State (Bauchi: Alkaleri and Giade LGAs; Cross River State: Yala and Etung LGAs) from the list of rural LGAs in each state. A list of PHC facilities offering maternal, newborn and child health services was stratified as Health posts, Primary Health Clinics and Primary Healthcare Centres; subsequently an equal representation of the different types of facilities was selected. Sixty-six (66) randomly selected primary healthcare facilities in Bauchi and Cross River States were involved. These health facilities represent half of all the available primary healthcare facilities in the randomly selected rural LGAs within the study States, based on a sampling approach used by Adeniyi and colleagues14.
The researchers applied a purposive sampling strategy for client selection such that a cross-section of female clients who were accessing maternal newborn and child health services from primary healthcare health facilities were involved in this study. This study was part of a larger study undertaken to assess primary healthcare service delivery, using 66 health facilities across two states in Nigeria. For this study focused on assessing female clients’ gender preferences, the selection criteria was such that only health facilities among the 66 health facilities which recorded frontline health workers attending to an average of at least 7 patients/clients per day (determined by analysing data from the larger study) were purposively included within the study sample for this study assessing female clients’ gender preferences. Based on this selection criteria, all female clients who accessed the selected health facilities for maternal, newborn and child health services during the data collection period of the larger study were enrolled in this study. Thus, 256 women who accessed MNCH services from frontline healthcare providers in the selected health facilities for the study, either for themselves, their newborn or under-five children and willing to participate in the study were enrolled to participate in client exit interviews for the study.
Data collection and analysis
Pre-tested questionnaires (see Additional file 1) were uploaded on personal digital assistants (PDAs) to facilitate the data collection process. During fieldwork the study supervisors made spot-checks on completed questionnaires, and any irregularities were corrected before the data was sent to the database designed for the study. Data analysis was carried out with SPSS software. Descriptive analysis of the data was carried out using percentage frequency distribution tables. Bivariate analyses of the data were also conducted. Fishers’ Exact test was employed during bivariate analysis (partly due to the small sample size) to explore relationships between female clients’ gender preference and some key characteristic variables such as location, pregnancy status and gender of health worker(s) seen at health facilities.