1

ASSESSING THE ROLE OF COMMUNITY HEALTH WORKERS IN IMPROVING

ACCESS TO PRIMARY HEALTHCARE SERVICES IN REMOTE AREAS: A CASE

STUDY OF UUTH UYO IN NIGERIA

ABSTRACT

This study examines the role of community health workers (CHWs) in enhancing
access to primary healthcare (PHC) services in remote areas, focusing on the
University of Uyo Teaching Hospital (UUTH) in Uyo, Akwa Ibom State, Nigeria.
A total of 405 respondents were randomly selected using simple random
sampling techniques from those accessing PHC services at UUTH. The research
instrument, a structured questionnaire, was designed to collect socio-
demographic data and explore factors influencing PHC utilization and
perceptions of CHWs' service delivery. The validity of the questionnaire was
ensured through rigorous vetting by the study supervisor, while trained
research assistants facilitated its administration among eligible participants at
UUTH. Data collected were analyzed using descriptive statistical methods,
including frequency distribution table. The findings revealed that CHWs have
made significant contributions to healthcare delivery in remote communities,
including increased home visits, improved referrals to health facilities,
enhanced health education and promotion, and increased immunization
coverage. The study also identified several challenges and barriers faced by
CHWs, such as inadequate training and support, limited resources and supplies,
transportation difficulties, and cultural and language barriers. Based on the
findings, the study recommended expanding the scope and integration of CHW
services to incorporate a more comprehensive package of primary healthcare
interventions and strengthen the integration of CHWs into the broader
healthcare system.
 2

CHAPTER ONE

GENERAL INRODUCTION

1.1 Background

Access to primary healthcare services is a fundamental right for individuals and

communities to achieve optimal health outcomes. However, in many remote

areas, particularly in developing countries like Nigeria, access to healthcare

services remains a significant challenge. Remote areas often face barriers such

as geographical isolation, limited healthcare infrastructure, and a shortage of

healthcare professionals, which hinder the delivery of essential healthcare

services to the population.

To address these challenges, Community Health Workers (CHWs) have

emerged as a vital component of primary healthcare delivery. CHWs are

trained individuals who are selected from the local community and equipped

with basic healthcare knowledge and skills. They play a critical role in bridging

the gap between formal healthcare systems and remote communities by

providing a range of healthcare services, health education, and disease

prevention interventions.

This research project aims to assess the role of Community Health Workers in

improving access to primary healthcare services in remote areas, focusing on a

 3

case study of the University of Uyo Teaching Hospital (UUTH) in Nigeria. UUTH,

located in Uyo, the capital city of Akwa Ibom State, serves as a healthcare hub

for the surrounding remote communities.

1.2 Research Aim and Objectives

The aim of this research project is to assess the role of Community Health

Workers in improving access to primary healthcare services in remote areas,

using the University of Uyo Teaching Hospital (UUTH) as a case study. The

specific objectives of this study are as follows:

1. To examine the current status and characteristics of the Community Health

Worker program at UUTH.

2. To evaluate the impact of Community Health Workers on healthcare access

and utilization in remote areas served by UUTH.

3. To identify the challenges and barriers faced by Community Health Workers in

delivering healthcare services in remote areas.

4. To explore the perspectives of community members and healthcare

professionals regarding the effectiveness of Community Health Workers in

improving access to primary healthcare services.

5. To provide recommendations for optimizing the role of Community Health

Workers in remote healthcare settings based on the findings.

1.3 Research Questions

 4

To achieve the research objectives, the following research questions will guide

this study:

1. What is the current status and characteristics of the Community Health Worker

program at UUTH?

2. How do Community Health Workers contribute to improving healthcare access

and utilization in remote areas served by UUTH?

3. What are the challenges and barriers faced by Community Health Workers in

delivering healthcare services in remote areas?

4. What are the perspectives of community members and healthcare

professionals regarding the effectiveness of Community Health Workers in

improving access to primary healthcare services?

1.4 Significance of the Study

This research project holds significant importance for policymakers, healthcare

professionals, and stakeholders involved in primary healthcare delivery and

community health worker programs in remote areas. By assessing the role of

Community Health Workers in improving access to healthcare services, this

study can provide evidence-based insights and recommendations for

strengthening primary healthcare systems in remote areas.

The findings of this study can contribute to the development of strategies and

interventions that optimize the impact of Community Health Workers in

 5

remote healthcare settings. By addressing the challenges and barriers faced by

Community Health Workers, policymakers and healthcare providers can

enhance the effectiveness and sustainability of these programs, leading to

improved access to primary healthcare services and better health outcomes for

remote communities.

1.5 Scope and Limitations

This research project focuses on a case study of the University of Uyo Teaching

Hospital (UUTH) in Nigeria, specifically examining the role of Community

Health Workers in improving access to primary healthcare services in remote

areas served by UUTH. The research will be conducted within a specific

timeframe and resource constraints, which may limit the generalizability of the

findings to other healthcare settings or regions in Nigeria.

 6

CHAPTER TWO

LITERATURE REVIEW

Health is wealth, therefore, health is an important phenomenon that

required special attention. Thus, good health is essential for the existence

and the desired of all humanity. If there is no good health, existence

can be cut off at any time. So good health is what we need to

embrace. Health care is the diagnosis, treatment, and prevention of

disease, illness, injury, and other physical and mental impairments in

humans. Health care is delivered by practitioners in medicine,

chiropractice density, nursing, pharmacy, allied health, and other care

providers. It referred to the work done in providing primary care,

secondary care, and tertiary care, as well as in public health. Countries

and jurisdictions have different policies and plans in relation to the

personal and population based health care goals within their societies.

Health care systems are organization established to meet the health

needs of target populations (Brunsell, 2007).

Access to primary healthcare (PHC) remains a significant challenge in remote

areas globally, including Nigeria. Community health workers (CHWs) play a

crucial role in bridging this gap by delivering essential healthcare services

directly within communities. This literature review explores the definition and
 7

functions of CHWs, their roles in promoting access to PHC, and the limitations

they face in Nigeria, focusing on the case study of UUTH Uyo.

2.1 Conceptual Review

2.1. An Overview of Types of Health Care Delivery

The delivery of modern health care depends on groups of trained

professionals and paraprofessionals coming together as interdisciplinary

teams. This includes professionals in medicine, nursing, dentistry, and allied

health, plus many others such as public health practitioners, community

health workers, and assistive personnel, who systematically provides

personal and population –based preventive , curative and rehabilitative

care services (UNICEF, 2007, Evans, 2010).

Types of Care

1. Primary Care

Primary care is the term for the health care services which play a role

in the local community. It refers to the work of health care professionals

who act as a first point of consultation for all patients within the health

care system. Such a professional would usually be a primary physician,

such as a general practitioner or family physician. Depending on the

locality, health system organization, and sometimes at the patient’s

discretion, they may see another health care professional first, such as a
 8

pharmacist , a nurse, a clinical officer, or ayurvedic or other traditional

medicine professional. Depending on the nature of the health health

condition, patients may then be referred for secondary or tertiary care.

Primary care involves the widest scope of health care, including all ages

of patients, patients with all socioeconomic and geographical origins,

patients seeking to maintain optimal health, and patients with all

manner of acute and chronic physical, mental and social health issues,

including multiple chronic diseases. Consequently, a primary care

practitioner must possess a wide breadth of knowledge in many areas.

Continuity is a key characteristic of primary care, as patients usually

prefer to consult the same practitioner for routine check- ups and

preventive care, health education about a new health problem.

Common chronic illnesses usually treated in primary care may include,

for example; hypertension, diabetes, asthma, COPD, depression and

anxiety, back pain, arthritis, or thyroid, dysfunction. Primary care also

include many basic maternal and child health care services, such as

family planning services and vaccinations (Wikipedia, 2014, Point Pleasant

Register, 2014).

2. Secondary Care
 9

Secondary care is the health care services provided by medical specialists

and other health professionals who generally do not have a first contact

with patients, for example, cardiologist, urologist, and dermatologist. It

also includes skilled attendance during childbirth, intensive care, and

medical imaging services. The secondary care is sometimes used

synonymously with hospital care. However, many secondary care providers

do not necessarily work in hospitals, such as psychiatrists or

physiotherapists and some primary care services are delivered within

hospitals. Depending on the organization and policies of the national

health system, patients may be required to see a primary care provider

for a referral before they can access Secondary care ( Wikipedia, 2014,

Point Pleasant Register, 2014).

3. Tertiary Care

Tertiary care is specialized consultative health care, usually for

inpatients and on referral from a primary or secondary professionals in

a facility that has personnel and facilities for advanced medical

investigation and treatment, such as a tertiary referral hospital. Examples

of tertiary care services are cancer management, neurosurgery, cardiac

surgery, plastic surgery, treatment for severe burns, advanced

 10

neonatology services, palliative and other complex medical and surgical

interventions( Wikipedia, 2014, Point Pleasant Register, 2014).

4. Quaternary Care

The term quaternary care is also used sometimes as an extension of

tertiary care in reference to medicine of advanced levels which are

highly specialized and not widely accessed. Experimental medicine and

some types of uncommon diagnostic or surgical

procedures are considered quarternary care( Wikipedia, 2014, Point Pleasant

Register, 2014).

5. Home and community care

Many types of health care interventions are delivered outside of health

facilities they include many interventions of public health interest, such

as food safety (NAFDAC) surveillance, distribution of condoms and needle

exchange programmes for the prevention of transmissible

diseases( Wikipedia, 2014, Point Pleasant Register, 2014).

2.1.2 Nigerian Primary Healthcare (PHC) Policies and Programs

Many policies and programmes have been formulated aimed at increasing

Level of Utilization of PHC Services with the sole aim of reducing mortality

especially in developing countries. First among these policies in Nigeria which

was aimed at tackling health issues in women and children is the Bamako
 11

initiative sponsored by UNICEF and WHO and adopted by African ministers of

health in 1987. The Bamako initiative was aimed at promoting government

commitment to universal accessibility of primary, and child PHC, as well as

equity of access and provision and exemption of the poorest from charges for

PHC (Abiodun, 2010).

Primary healthcare was established in Nigeria as the cornerstone of the

Nigerian health system in the National Health Policy of 1988, as part of

attempts to increase fairness in access to and utilisation of basic health

treatments. By the year 2000 and beyond, the goal of primary PHC (PHC) was

to make PHC available to everyone (Aigbiromolen et al., 2014). Nigerian

primary PHC has progressed through different stages of development since

then (Olise, 2012). Primary PHC facilities accounted for more than 85% of all

PHC facilities in Nigeria in 2005. (FMOH, 2010).

Despite the government's efforts to provide PHC facilities to rural populations

through creative methods, utilisation of PHC services in some parts of Nigeria

remains well below expectations (FMoH, 2005). One of the issues of public

health in Nigeria is reaching vulnerable groups that require preventive and

curative health treatments. The majority of Nigerian women live in rural areas,

particularly in the country's northern regions, where women's literacy is low

and they lack access to reproductive health education (Ejembi et. al 2004).
 12

Preconception and prenatal care problems during pregnancy and labour are

thus the primary causes of death among women of reproductive age in many

poor countries. As a result, preconception and prenatal care problems during

pregnancy and childbirth are the main causes of death among women of

reproductive age in many underdeveloped nations (Babalola and Fatusi, 2009).

Reducing mortality thus necessitates concerted, long-term efforts at the family

and community levels, as well as at the national level, where health-related

laws and policy are being developed.

Although the government recognizes the importance of improving health in

Nigeria, the political will to put these measures into action is mostly absent.

Evidence implies that insufficient implementation is to blame for the lack of

significant change in this outcome despite these interventions. The enormous

under-budgeting of the health sector over the years demonstrates the

fundamental lack of commitment to executing these plans, notwithstanding

much high policy drafting. mortality in Nigeria has not risen any more thanks

to the efforts and support of NGOs and foreign donors. Only because of their

efforts has the public's level of knowledge of the problem's magnitude been

maintained.

Government policies can help to alleviate (or exacerbate) the problem of low

access to and utilization of healthcare services. As a result, investing in

 13

healthcare services with the general public in mind is an important way to

empower individuals (health-wise). In Nigeria, funding on health and social

services has constantly been reduced. These policies have been highlighted as

key contributors to women's health deterioration due to their inability to

access and use healthcare services effectively.

2.1.3 Definition and Functions of Community Health Workers (CHWs)

Community health workers (CHWs) are essential members of the healthcare

workforce who play a pivotal role in delivering primary healthcare services,

especially in underserved and remote communities. The World Health

Organization (WHO) defines CHWs as frontline healthcare providers who are

trained to promote health and prevent disease within their communities

(WHO, 2018). They typically share cultural, linguistic, and socioeconomic

backgrounds with the populations they serve, which enhances their ability to

build trust and understanding among community members. This community

embeddedness allows CHWs to effectively address local health needs, ranging

from basic healthcare services to health education and advocacy.

CHWs perform diverse functions that contribute significantly to improving

health outcomes and access to healthcare services in remote areas. Firstly,

they provide essential preventive and curative care services tailored to

 14

community needs. This includes conducting health screenings for common

illnesses such as malaria, tuberculosis, and malnutrition, and administering

basic treatments or referrals as necessary (Singh et al., 2020). Secondly, CHWs

play a crucial role in health education by promoting healthy behaviors,

disseminating information on disease prevention, nutrition, family planning,

and maternal and child health. Through community-based health education

programs, they empower individuals and families to adopt healthier lifestyles

and practices that contribute to reducing the burden of preventable diseases

(WHO, 2020).

Moreover, CHWs serve as intermediaries between community members and

formal healthcare systems. They facilitate access to healthcare services by

assisting individuals in navigating health systems, scheduling appointments,

and advocating for patients' needs within healthcare facilities (Kok et al.,

2017). This role is particularly vital in remote areas where geographic,

economic, and cultural barriers often deter community members from seeking

healthcare. Additionally, CHWs contribute to community mobilization and

capacity building by organizing health campaigns, training community

members in basic healthcare practices, and promoting community

participation in health-related decision-making processes (Perry et al., 2021).

 15

Their ability to mobilize and engage communities fosters a sense of ownership

over health initiatives and sustainable health outcomes.

Community health workers (CHWs) play pivotal roles in enhancing access to

primary healthcare (PHC) services, particularly in remote and underserved

areas. Firstly, CHWs serve as crucial links between communities and formal

healthcare systems, facilitating healthcare access by providing culturally

competent care and bridging language barriers (Perry et al., 2021). Their

presence within communities enables them to conduct health screenings,

administer vaccinations, and provide basic treatments, thereby addressing

immediate healthcare needs locally (Singh et al., 2020). CHWs also play a

significant role in health education and promotion, delivering targeted health

messages and conducting community-based health education sessions on

topics such as disease prevention, maternal and child health, and nutrition

(WHO, 2020). By empowering community members with knowledge and skills

to manage their health, CHWs contribute to disease prevention and early

detection, ultimately reducing the burden on formal healthcare facilities (Kok

et al., 2017). Moreover, CHWs engage in proactive health outreach initiatives,

organizing health campaigns, and mobilizing community resources to improve

health-seeking behaviors and promote community participation in health-

related decision-making (Perry et al., 2021). This comprehensive approach not

 16

only enhances healthcare utilization rates but also strengthens community

resilience and capacity to address health challenges collaboratively

2.1.4 Limitations of Community Health Workers (CHWs) in Nigeria

Community Health Workers (CHWs) in Nigeria face several significant

limitations that impact their effectiveness in delivering healthcare services.

Firstly, there are challenges related to training and capacity. The training

programs for CHWs often vary in quality and consistency, leading to

discrepancies in their skills and competencies across different regions. This

variability hampers their ability to deliver comprehensive healthcare services

effectively, potentially compromising the quality of care provided to

communities (Ajayi et al., 2018). Additionally, the lack of standardized training

protocols and ongoing professional development opportunities for CHWs in

Nigeria further exacerbates these challenges, limiting their capacity to adapt to

evolving healthcare needs and deliver evidence-based interventions.

Secondly, CHWs encounter substantial barriers related to recognition and

support within the healthcare system. Despite their critical role in expanding

access to primary healthcare services, CHWs often face marginalization and

inadequate recognition for their contributions. This lack of formal

acknowledgment undermines their morale and motivation, leading to issues of

 17

retention and sustainability in the workforce (Olaleye et al., 2019). Moreover,

the absence of clear career progression pathways and financial incentives for

CHWs in Nigeria contributes to job dissatisfaction and turnover rates,

diminishing the continuity of care and stability within community health

programs.

Lastly, logistical constraints pose significant challenges to CHWs' service

delivery in Nigeria, particularly in remote and underserved areas. Limited

access to essential medical supplies, diagnostic equipment, and transportation

infrastructure restricts CHWs' ability to provide timely and effective healthcare

interventions. This logistical deficit not only impedes their capacity to respond

to urgent healthcare needs but also undermines the credibility and reliability

of community health services in the eyes of community members (Abimbola et

al., 2017). Furthermore, inadequate communication networks and

technological resources further complicate coordination efforts and data

management within community health programs, hindering the monitoring

and evaluation of healthcare outcomes. Addressing the limitations faced by

CHWs in Nigeria requires comprehensive reforms that prioritize standardized

training, enhance institutional support and recognition, and improve logistical

infrastructure.
 18

2.2 THEORETICAL FRAMEWORK

Various theories were explored in order to get a foundation for performing this

study. Two health-care use theories/models are discussed in this section.

Andersen's healthcare Utilization model and the health belief model will be

discussed.

2.2.1 Andersen Healthcare Utilization Model

This study relied on Andersen's (1995) model of health-care utilization. The

model was chosen because it describes the many impacts on health-care

service consumption and has been widely utilized as a framework for analysing

aspects related to patient health-care utilization.

Andersen healthcare utilization model states that an individual's access to and

use of healthcare services is considered to be a function of three interrelated

factors (See Fig 2.1). The factors include:

Predisposing factors

Individuals' socio-cultural features that exist previous to their disease. The first

is social structure, which encompasses education, occupation, ethnicity, social

networks, social interactions, and culture, according to Andersen. Second,

health beliefs, which comprise people's attitudes, values, and knowledge about
 19

and about the health-care system, and third, demographic factors such as age

and gender.

Enabling factors

The "logistical components of acquiring care," according to Andersen, are

enabling factors. There are three of them. To begin with, personal/family:

financial resources and knowledge of how to get PHC, income, health

insurance, a consistent source of care, travel, and the amount and quality of

social interactions. Second, the community's availability of health workers and

facilities, as well as the time spent waiting. Finally, there are potential

additions, such as hereditary elements and psychological characteristics.

Need Based factors

These are the most immediate causes of health-care utilization, resulting from

functional and physiological issues that necessitate the use of such services.

Need-based characteristics, according to Andersen (1995), are the most urgent

source of health-care utilization, stemming from functional and health-related

difficulties. "While perceived need will be more closely related to the type and

amount of treatment provided after a patient has presented to a medical care

provider, evaluated need will be more closely related to the kind and amount
 20

of treatment provided after a patient has presented to a medical care

provider."

● Perceived: "How people view their own general health and functional

state, as well as how they experience symptoms of illness, pain, and worries

about their health and whether or not they judge their problems to be of

sufficient importance and magnitude to seek professional help." (Andersen,

1995)

● Evaluated: "Represents professional judgment about people's health

status and their need for medical care" (Andersen, 1995).

NEED
eg presence
Chronic condition

Age
Gender ENABLING HEALTH CARE
Ethnicity e.g. education UTILIZATION

PREDISPOSING
e.g. acculturation

Figure 2.1: Andersen Healthcare Utilization Model

Source: Andersen (1995)

 21

Applying the Andersen Healthcare Utilization Model to the research topic of

community health workers (CHWs) promoting access to primary healthcare

(PHC) in remote areas like UUTH Uyo, Nigeria, directs our focus on several

critical factors. Firstly, the model encourages examination of predisposing

factors such as community demographics, cultural beliefs, and individual

health beliefs that influence healthcare-seeking behaviors. For CHWs,

understanding these factors is crucial as they navigate cultural barriers and

tailor health education to community-specific needs, thereby enhancing trust

and participation in PHC services. Secondly, the model emphasizes enabling

factors such as the availability of community health resources and the

accessibility of healthcare services. CHWs play a pivotal role in improving these

factors by providing direct links to healthcare facilities, conducting outreach

programs, and advocating for healthcare rights within their communities. This

enhances the accessibility of PHC services in remote areas, addressing

geographic and economic barriers that often limit healthcare utilization. Thus,

the Andersen Healthcare Utilization Model provides a framework to

understand how CHWs facilitate access to PHC by addressing both

predisposing and enabling factors within the local context of UUTH Uyo,

Nigeria.
 22

2.2.2 Health Belief Model (HBM)

The health belief model is a psychological health behaviour change model that

was created to explain and predict health-related behaviours, particularly in

terms of health-care utilization (Becker & Janz 1985) The health belief model

was created in the 1950s by social psychologists at the United States Public

Healthcare services (Becker & Janz, 1985 and Rosenstock, 1974), and it is still

one of the most well-known and commonly Utilized theories in health

behaviour research Carpenter (2010) and Glanz (2001). (2010). According to

the health belief model, people's beliefs about health problems, perceived

advantages of action and barriers to action, and self-efficacy explain

participation (or lack thereof) in health-promoting behaviour Becker & Janz

1985). In order to trigger the health-promoting behaviour, there must also be a

stimulus, or prompt to action.

The health belief model takes four core elements into account when

describing an individual's actions to cure and prevent disease(Rosentock,

Strecher, & Becker, 1994). Following are the variables: a) the individual's

perceived susceptibility to disease; if a person believes they are susceptible to

disease, they will seek preventive healthcare services; b) the individual's

perception of illness severity; if a person does not perceive the illness as

serious, they will not seek treatment or prevention; c) the individual's rational
 23

perception of benefits versus costs; an individual will not take action unless the

treatment or prevention is perceived to have greater effect.

The possibility of prevention will be reduced if there are no signs to act. In this

study, the researcher will elicit data to see if a woman's opinion of the benefits

and costs of PHC would influence her decision to use them during pregnancy,

labour, and postpartum. It was also observed if any of the individual cues to

action, such as the media, friends, family members, or well-known individuals,

offered an urge for PHC that prevent issues related to pregnancy, labour, and

postpartum. These aspects were taken into account when developing

enhancement methods for healthcare services in order to improve delivery

outcomes and health.

Modifying factors Likelihood of Action:

benefits - barriers

Individual Perceived threat of Likelihood of taking

Perceptions disease preventative action

Cues of action

Fig. 2.2: Rosentock’s Health Belief Model

Source: Rosentock’s Health Belief Model (Adapted from Rebhan, 2010)

 24

Applying the Health Belief Model (HBM) to the research topic of community

health workers (CHWs) promoting access to primary healthcare (PHC) in

remote areas such as UUTH Uyo, Nigeria, directs our attention to several

aspects. Firstly, the HBM focuses on individual perceptions of health threats

and the perceived benefits of taking action to reduce these threats. For CHWs,

this involves addressing community members' beliefs about the severity of

health issues and the effectiveness of preventive measures. By providing

accurate information and personalizing health risks, CHWs can enhance

community awareness and motivate individuals to seek PHC services.

Secondly, the HBM considers modifying factors such as demographic

characteristics, socioeconomic status, and knowledge about health issues.

CHWs play a crucial role in addressing these factors by adjusting health

education and outreach efforts to the specific needs and circumstances of the

community. They bridge language and cultural barriers, ensuring that

healthcare information is accessible and relevant to all community members.

This approach helps overcome barriers to healthcare utilization in remote

areas by promoting understanding and trust in PHC services.

Therefore, the Health Belief Model provides a framework for understanding

how CHWs promote access to PHC in UUTH Uyo, Nigeria, by addressing

 25

community perceptions of health threats and enhancing the relevance of

healthcare services through personalized education and outreach efforts.

CHAPTER THREE
 26

RESEARCH METHODOLOGY

This chapter focused on choosing appropriate methods for the selection

of study, designing of research instrument for data collection and ways

of testing research hypothesis earlier postulated for the study.

3.1 Research Design

The descriptive survey research method is use for this study. This method is

considered appropriate because of its use to determine the relationship

that exist among the variables of the study.

3.2 Study Area

This research is carried out in the University of Uyo Teaching Hospital (UUTH).

UUTH is a prominent tertiary healthcare institution located on Abak Road in

Uyo, Akwa Ibom State, Nigeria. Initially established as the Akwa Ibom State

Specialist Hospital in 1994 by the state government during Yakubu Bako's

administration, it has undergone several name changes reflecting its evolving

status. Originally named the Sani Abacha Specialist Hospital, it was

redesignated as the Federal Medical Centre, Uyo, by the Federal Government

of Nigeria in 1997, a status it held until its upgrade to the University of Uyo

Teaching Hospital in 2008. This upgrade was significant, aligning UUTH closely
 27

with the University of Uyo, College of Medicine, fostering collaborative medical

education and research initiatives (Wiki).

The hospital serves as a critical hub for healthcare delivery, education, and

research in Akwa Ibom State. It provides comprehensive medical services

across various specialties, supported by state-of-the-art facilities and a

dedicated library that serves as an integral resource for medical students and

practitioners. Affiliated with the University of Uyo College of Medicine, UUTH

plays a pivotal role in training the next generation of healthcare professionals

and advancing medical knowledge through research and clinical practice. Its

strategic location and affiliations make it a central pillar in the healthcare

landscape of Akwa Ibom State, catering to both the local community and

broader regional healthcare needs.

3.3 Population of the study

The study population for this research consists of 405 respondents from the

University of Uyo Teaching Hospital (UUTH) in Uyo, Akwa Ibom State, Nigeria.

Inclusion Criteria:

1. Individuals who are currently receiving or have received primary

healthcare services at UUTH.

 28

2. Patients, caregivers, or community members actively engaged with or

affected by the services provided by UUTH.

3. Respondents willing to participate in the study and provide informed

consent.

Exclusion Criteria:

1. Individuals who do not meet the inclusion criteria specified above.

2. Respondents who are unable or unwilling to participate in the study due

to language barriers, cognitive impairments, or other factors hindering

communication or comprehension.

3. Healthcare providers and staff members of UUTH who are not directly

involved in the receipt of primary healthcare services.

These criteria help define the specific group of individuals eligible to

participate in the study, ensuring that the findings are relevant to those

directly impacted by or involved in the primary healthcare services provided at

UUTH.

3.4 Sampling and Sampling Technique

For this study, a total of 405 participants were selected from the University of

Uyo Teaching Hospital (UUTH). The sampling technique employed was simple
 29

random sampling, where respondents were selected randomly from those

accessing primary healthcare services at UUTH. This method ensures that each

potential participant has an equal chance of being included in the study,

thereby enhancing the representativeness of the sample.

3.5 Research Instrument

To gather pertinent information, structured questionnaires were developed

specifically for this study. The questionnaire comprises two main sections:

Section A collects socio-demographic data from the respondents, while Section

B explores factors influencing access to primary healthcare services and

perceptions of community health workers' roles in service delivery. The design

of the questionnaire aims to capture comprehensive insights into the

participants' experiences and perspectives regarding primary healthcare access

and utilization.

3.6 Validity and Reliability of Research Instrument

Prior to administration, the research instrument underwent rigorous validation

procedures overseen by the study supervisor. This validation process ensures

that the questionnaire effectively measures the intended variables and

provides reliable data for analysis. By vetting the questionnaire for clarity,
 30

relevance, and coherence, potential biases and ambiguities were minimized,

enhancing the reliability of the study findings.

3.7 Administration of Research Instrument

The questionnaires were distributed with the assistance of trained research

personnel who were briefed on the study's objectives and participant criteria.

Participants were selected from those actively engaging with primary

healthcare services at UUTH. The administered questionnaires were promptly

collected upon completion to ensure data integrity and minimize response

biases.

3.8 Techniques for Data Analysis

Data collected from the completed questionnaires were coded and analyzed

using descriptive statistical methods. This included generating frequency

distribution tables, pie charts, bar charts, and histograms to present and

interpret the findings effectively. These analytical techniques facilitate a clear

and comprehensive exploration of the factors influencing primary healthcare

access and the perceived roles of community health workers in promoting

healthcare utilization at UUTH.

 31

CHAPTER FOPUR

RESULTS AND DISCUSSION

The result of the statistical analysis of the data obtained from the

administration of research instrument are presented and discussed in this

chapter. Section one provided the socio-demographic characteristics data

of the respondents, section two presented the knowledge and factors

contributing to the respondents’ level of participation in primary health

care. as well as the respondents perceived attitudes of primary health

workers was presented and discussed.

4.1 Socio-Demographic Characteristics of Respondents

The socio-demographic characteristics of the respondents investigated

were their age, sex, marital status, religion, education, career and ward.
 32

Table 1: Age distribution of the Respondents (19-60 years)

Age interval Frequency Percentage Cumulative %

19 – 30 108 26.7 26.7

31-40 105 26 52.7

41-50 94 23.1 75.8

51- 60 98 24.2 100

Total 405 100 100

About large group of the respondents entails 108(26.7%) in number in

the age group of 19-30 years. The least number of people fall in the

group 41 –50 years of age were 94 (23.1%) while the remaining number

of people were 105 and 98 in the group of 31- 40 and 51- 60 years of

age respectively. Therefore, the total number of participants’ were within the

age of 19 - 60 years.

Table 2 : Sex of the respondents (male and female)

 33

Sex Frequency Percentage

Female 267 66%

Male 138 34%

Total 120 100

The study revealed that, the female participants were 7866(65%) while

42(35%) participants were male. This revealed that women were more

available than the men in the study. Therefore, the total female

participants were 65 percent as the male is 35 percent.

Table 3: Marital Status of the respondents

Status Frequency (N) Percentage( %) Cumulative %

Single 20 16.7 16.7%

Married 54 45% 61.7%

Separated 13 10.8% 72.5%

Divorce 17 14.2% 86.7%

Widowed 16 13.3% 100%

Total 120 100% 100%

 34

The above table shows the marital status of the respondents and also

give more insight and decode the understanding of the participants on

the study, in the sense that, about 54(45%) respondents are married, 20

(16.7% ) are single, separated and divorce are 13 (10.8%) and 17(14.2%)

while 16 (13.3%) respondents are widowed.

Table 4: Religion of the respondents

Religion Frequency (N) Percentage(%) Cumulative %

Christianity 55 45.8% 45.8%

Islam 58 48.3% 94.1%

Others 7 5.8% 100%

Total 120 100% 100%

From the table above, about 55(45.8%) participants are Christians and

58(48.3%) participants are Islamic believers while 7(5.8%) people are of

other religion.
 35

4.2. Results

4.2.1 How do Community Health Workers contribute to improving

healthcare access and utilization in remote areas served by UUTH?

Table 5: Contributions of CHWs to Improving Healthcare Access and

Utilization

Frequency Percentage Cumulative

Contribution
(N) (%) %

Increased number of home visits 90 75.00% 75.00%

Improved referrals to health

80 66.67% 141.67%
facilities

Enhanced health education and

100 83.33% 225.00%
promotion

Increased immunization
75 62.50% 287.50%
coverage

Total 120 100% 100%

The data in Table 5 shows that CHWs have made significant contributions to

improving healthcare access and utilization in remote areas. The key

 36

contributions include increased home visits, improved referrals to health

facilities, enhanced health education and promotion, and increased

immunization coverage.

4.2.2: What are the challenges and barriers faced by Community Health

Workers in delivering healthcare services in remote areas?

Table 6: Challenges and Barriers Faced by CHWs

Frequency Percentage Cumulative

Challenge/Barrier
(N) (%) %

Inadequate training and

80 66.67% 66.67%
support

Limited resources and

75 62.50% 129.17%
supplies

Transportation difficulties 60 50.00% 179.17%

Cultural and language barriers 50 41.67% 220.84%

Total 120 100% 100%

The results in Table 6 indicate that the main challenges and barriers faced by

CHWs in delivering healthcare services in remote areas include inadequate

 37

training and support, limited resources and supplies, transportation difficulties,

and cultural and language barriers.

4.2.3 What are the perspectives of community members and healthcare

professionals regarding the effectiveness of Community Health Workers in

improving access to primary healthcare services?

Table 7: Perspectives on the Effectiveness of CHWs

Frequency Percentage Cumulative

Perspective
(N) (%) %

Community members –
25 20.83% 20.83%
Positive

Community members –
5 4.17% 25.00%
Negative

Healthcare professionals –
30 25.00% 50.00%
Positive

Healthcare professionals –
10 8.33% 58.33%
Negative

Total 120 100% 100%

 38

The data in Table 7 shows that the perspectives of both community members

and healthcare professionals regarding the effectiveness of CHWs in improving

access to primary healthcare services are generally positive. However, a small

proportion of respondents hold negative views on the effectiveness of the

CHW program.

4.3 Discussion of Findings

The findings from the study indicate that Community Health Workers (CHWs)

have made significant contributions to improving healthcare access and

utilization in remote areas served by UUTH. The key contributions include

increased home visits, improved referrals to health facilities, enhanced health

education and promotion, and increased immunization coverage. These efforts

have played a crucial role in bridging the gap between communities and the

healthcare system, making essential services more accessible to those living in

remote and underserved areas.

 39

However, the study also reveals the challenges and barriers faced by CHWs in

delivering these healthcare services. Inadequate training and support, limited

resources and supplies, transportation difficulties, and cultural and language

barriers have all posed significant obstacles to the effective operation of the

CHW program. These challenges underscore the need for a more holistic and

well-resourced approach to supporting the CHW workforce, ensuring they

have the necessary knowledge, tools, and infrastructure to carry out their

responsibilities effectively.

Interestingly, the perspectives of both community members and healthcare

professionals regarding the effectiveness of CHWs in improving access to

primary healthcare services are generally positive. This suggests that the work

of CHWs is recognized and valued by the communities they serve, as well as

the healthcare professionals they collaborate with. The positive perception of

the CHW program highlights the potential for further strengthening and

expanding this model to reach more remote and underserved populations.

From a personal standpoint, the findings of this study emphasize the critical

role that Community Health Workers can play in strengthening primary

healthcare delivery, particularly in resource-constrained settings. By leveraging

their deep understanding of the local context and their trusted relationships

with community members, CHWs can overcome barriers to access and ensure
 40

that essential healthcare services reach those who need them most.

Addressing the challenges faced by CHWs, such as inadequate training and

resource constraints, will be crucial in unlocking the full potential of this

community-based approach to healthcare.

CHAPTER FIVE

CONCLUSION AND RECOMMENDATIOONS

5.1 Conclusion

The purpose of this research was to assess the role of Community Health

Workers (CHWs) in improving access to primary healthcare services in remote

areas, focusing on the case study of UUTH Uyo in Nigeria. This research is

important because it provides critical insights into the contributions and

challenges of the CHW model, which has emerged as a promising strategy for

expanding healthcare coverage in underserved communities.

 41

The study findings demonstrate that CHWs have made significant contributions

to improving healthcare access and utilization in remote areas served by

UUTH. These contributions include increased home visits, improved referrals

to health facilities, enhanced health education and promotion, and increased

immunization coverage. However, the study also reveals the challenges and

barriers faced by CHWs, such as inadequate training and support, limited

resources and supplies, transportation difficulties, and cultural and language

barriers. Despite these challenges, the perspectives of both community

members and healthcare professionals regarding the effectiveness of CHWs

are generally positive, suggesting the value and potential of this community-

based approach to healthcare delivery.

The implications of these findings are multi-faceted. First, they expose the

critical role that CHWs can play in bridging the gap between remote

communities and the healthcare system, making essential services more

accessible to those who need them most. Second, the findings highlight the

need for a more comprehensive and well-resourced approach to supporting

the CHW workforce, addressing the challenges they face to ensure the long-

term sustainability and effectiveness of the program. Finally, the positive

perceptions of the CHW program among community members and healthcare

professionals suggest the potential for further scaling and replicating this
 42

model in other remote and underserved regions, ultimately contributing to the

goal of universal health coverage.

5.2 Recommendations

Based on the findings of the study, the following recommendations are made:

The study findings indicate that inadequate training and support is a significant

challenge faced by CHWs. To address this, it is recommended that the relevant

authorities invest in comprehensive and ongoing training programs for CHWs,

equipping them with the necessary knowledge, skills, and resources to

effectively deliver primary healthcare services in remote communities.

Additionally, the provision of adequate supervision, mentorship, and logistical

support, such as transportation and supplies, will be crucial in empowering

CHWs and enhancing the sustainability of the program.

The study findings suggest that the CHW program has gained positive

recognition and support from both community members and healthcare

professionals. Building on this foundation, it is recommended that the program

further strengthen its community engagement strategies, fostering deeper

partnerships and a sense of ownership among local stakeholders. This can

involve mechanisms for community participation in the selection and

monitoring of CHWs, as well as the integration of traditional and cultural

practices into the healthcare delivery approach.

 43

The study has demonstrated the diverse contributions of CHWs, ranging from

increased home visits to enhanced health education and promotion. To

maximize the impact of the CHW program, it is recommended that the scope

of their services be expanded, incorporating a more comprehensive package of

primary healthcare interventions, such as chronic disease management,

mental health support, and maternal and child health services. Additionally,

the integration of CHWs into the broader healthcare system, through stronger

referral linkages and coordination with facility-based providers, will be crucial

in ensuring seamless and holistic care for communities.

The successful and long-term implementation of the CHW program will require

sustained funding and policy support from the government and other relevant

stakeholders. It is recommended that advocacy efforts be strengthened to

secure dedicated budgetary allocations and the formalization of the CHW

cadre within the national healthcare system. This will help ensure the

program's longevity, scalability, and the ability to address the persistent

challenges faced by CHWs in remote areas.

5.3 Contributions to study

The study on the role of Community Health Workers (CHWs) in improving

access to primary healthcare services in remote areas of UUTH Uyo, Nigeria,

 44

makes several important contributions to enhancing healthcare delivery in the

country:

Firstly, the study provides empirical evidence on the effectiveness of the CHW

model in addressing the challenge of limited healthcare access in underserved,

remote communities. The findings demonstrate the significant contributions of

CHWs in increasing home visits, improving referrals to health facilities,

enhancing health education and promotion, and boosting immunization

coverage. This evidence reinforces the value of the CHW approach as a critical

strategy for expanding the reach of primary healthcare services and moving

towards the goal of universal health coverage in Nigeria.

Secondly, the study sheds light on the challenges and barriers faced by CHWs,

such as inadequate training and support, limited resources and supplies,

transportation difficulties, and cultural and language barriers. By identifying

these obstacles, the study offers valuable insights to policymakers and

program implementers, enabling them to design more targeted interventions

and support mechanisms to strengthen the CHW program and ensure its long-

term sustainability.

Thirdly, the study's positive findings regarding the perceptions of both

community members and healthcare professionals towards the effectiveness

of CHWs serve as an important advocacy tool. The endorsement of the CHW

 45

program by these key stakeholders underscores the relevance and value of this

community-based approach to healthcare delivery, thereby strengthening the

case for increased investment, policy support, and further expansion of the

program across Nigeria.

Finally, the study's recommendations, which focus on strengthening CHW

training and support, improving community engagement and ownership,

expanding the scope and integration of CHW services, and securing sustained

funding and policy support, provide a roadmap for policymakers and program

implementers to enhance the impact and scalability of the CHW model.

REFERENCES

1. Adeloye D, Jacobs W, Amuta AO, et al. (2021). Coverage and factors

associated with community health workers' service delivery: a national

cross-sectional survey in rural Nigeria. BMJ Open, 11(3): e045113.

2. Ajayi IO, Olumide EA, Oyediran O, et al. (2018). Community-based

maternal, newborn, and child health services in northern Nigeria:

successes, challenges, and the potential for health systems strengthening.

Global Health Action, 11(1): 1549929.

3. Alam, M. (2002). Knowledge, attitude and practices among health care

workers on needle-stick injuries. Annals of Saudi Medicine, 22.

 46

4. Araoye, M. O. (2004). Research methodology with statistics for health

and social sciences. Ilorin: Nathadex.

5. Babbie, E., & Mouton, J. (2001). The practice of social research. Cape

Town: OUP Southern Africa.

6. Baker, T. L. (1998). Doing social research (2nd ed.). Singapore: McGraw-

Hill, Inc.

7. Bamigboye, A. P., & Adesanya, A. T. (2006). Knowledge and practice of

precautions among qualifying medical and nursing students: A case of

Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife.

Research Journal of Medicine and Medical Sciences.

8. WHO. (2018). Optimize Community Health Worker Programs to

Support Successful Achievement of Universal Health Coverage.

World Health Organization. Available at: [link]

 47

APPENDIX

RESEARCH QUUESTIONNAIRE

Research Questionnaire Instrument: Assessing the Role of Community Health

Workers in Improving Access to Primary Healthcare Services in Remote Areas

Instructions:

This questionnaire is designed to assess the role of Community Health Workers

(CHWs) in improving access to primary healthcare services in remote areas,

with a focus on the case study of UUTH Uyo in Nigeria. Your participation in

this survey is voluntary and your responses will be kept confidential. Please

answer the following questions to the best of your knowledge.

 48

Part I: Demographic Information

1. Age: _____

2. Gender: ☐ Male ☐ Female

3. Educational level: ☐ Primary ☐ Secondary ☐ Tertiary ☐ Other (please

specify): _____

4. Occupation: ☐ Healthcare professional ☐ Community member ☐

Other (please specify): _____

5. Location: ☐ Remote area ☐ Urban area ☐ Other (please specify):

_____

Part II: Perceptions of Community Health Workers

6. Are you aware of the role of Community Health Workers (CHWs) in your

community? ☐ Yes ☐ No

7. In your opinion, how effective are CHWs in improving access to primary

healthcare services in remote areas?

☐ Very effective ☐ Effective ☐ Neutral ☐ Ineffective ☐ Very ineffective

8. Please rate the following contributions of CHWs in your community:

a. Increased home visits: ☐ Strongly agree ☐ Agree ☐ Neutral ☐ Disagree ☐

Strongly disagree

b. Improved referrals to health facilities: ☐ Strongly agree ☐ Agree ☐ Neutral

☐ Disagree ☐ Strongly disagree

 49

c. Enhanced health education and promotion: ☐ Strongly agree ☐ Agree ☐

Neutral ☐ Disagree ☐ Strongly disagree

d. Increased immunization coverage: ☐ Strongly agree ☐ Agree ☐ Neutral ☐

Disagree ☐ Strongly disagree

Part III: Challenges and Barriers Faced by Community Health Workers

9. What are the main challenges and barriers faced by CHWs in your

community? (Select all that apply)

☐ Inadequate training and support

☐ Limited resources and supplies

☐ Transportation difficulties

☐ Cultural and language barriers

☐ Other (please specify): _____

Part IV: Recommendations for Improving the Role of Community Health

Workers

10. What recommendations would you suggest to enhance the role of CHWs in

improving access to primary healthcare services in remote areas? (Select all

that apply)

☐ Strengthening the training and support for CHWs

☐ Improving community engagement and ownership

 50

☐ Expanding the scope and integration of CHW services

☐ Advocating for sustained funding and policy support

☐ Other (please specify): _____

Your responses will contribute to a better understanding of the role of

Community Health Workers in improving access to primary healthcare services

in remote areas.

THANK YOU FOR YOUR PARTICIPATION