Maternal and child healthcare-seeking among victims of violence in armed conflict: A matched case-control study in northeast Nigeria
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Armed conflict severely impacts health, with indirect deaths often exceeding direct casualties by a factor of 2 to 4, disproportionately affecting women and children. Although the magnitude of these effects is well-documented, the mechanisms driving them remain insufficiently understood. This study shifts the focus from supply-side factors, such as the destruction of infrastructure, to demand-side processes, particularly healthcare-seeking behavior, and from broader conflict exposure to individual-level violent victimization.
Methods
Data come from a representative survey (n=3,006) of caregivers of young children in northeastern Nigeria, a region heavily affected by armed insurgency. Unlike previous studies, our survey included dedicated measures of victimization, health-seeking outcomes, and mediating factors within a single instrument, enabling precise measurement and analysis. A matched case-control design (651 cases and 651 controls) was used to assess the impact of individual-level victimization on maternal and child healthcare-seeking behavior, and causal mediation analysis to identify the mechanisms linking victimization to health outcomes.
Results
Victimization was widespread, with 21% of respondents (n=651) having experienced a severe form of violence in the past 3 years. While maternal healthcare-seeking behavior appeared unaffected, victimization significantly reduced healthcare-seeking for child health. Children of victimized caregivers were markedly less likely to be fully immunized (OR: 0.43, p<0.001) and to receive care at government health facilities (OR: 0.23, p<0.001). This decline was primarily driven by increased distrust in the health system (PM: 0.42–0.70, p<0.05), stemming from negative experiences during the conflict, particularly health worker absenteeism and victimization by state security forces.
Conclusion
Addressing fear and mistrust is key to improving healthcare-seeking in conflict- affected populations. Efforts should focus on providing security for government-run health facilities, reducing violence against civilians by state security forces, and restoring trust in healthcare and state institutions. Future research should explore effective strategies for achieving these objectives.
