Maternal and child healthcare-seeking among victims of violence in armed conflict: a quasi-experimental study in Northeast Nigeria.

introductionArmed conflict severely impacts health, with indirect deaths often exceeding direct casualties two to four times, 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 behaviour and from broader conflict exposure to individual-level violent victimisation.

methodsData come from a representative survey (n=3006) of caregivers of young children in northeastern Nigeria, a region heavily affected by armed insurgency. Unlike previous studies, our survey included dedicated measures of victimisation, health-seeking outcomes and potential mediating factors within a single instrument, enabling precise measurement and analysis. To compare maternal and child healthcare-seeking behaviour between victimised and non-victimised caregivers, we employed a quasi-experimental observational design using propensity-score matching on demographic and contextual characteristics. Causal mediation analysis was then used to identify the mechanisms linking victimisation to health behaviours.

resultsVictimisation was widespread, with 21% of respondents (n=651) having experienced a severe form of violence in the past 3 years. While maternal healthcare-seeking behaviour appeared unaffected, victimisation significantly reduced healthcare-seeking for child health. Children of victimised caregivers were markedly less likely to be fully immunised (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 (proportion mediated: 0.42-0.70, p<0.05), stemming from negative experiences during the conflict, particularly health worker absenteeism and victimisation by state security forces.

conclusionAddressing 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.