A nation relies on its educators to provide skills for upcoming learners and workers. To do this, they need to have good health security in their qualified positions. It is reasonable to expect that the National Health Insurance Scheme (NHIS) should effectively support this. The World Health Organization (WHO) posits that proper attention to workers' health and safety has extensive benefits as healthy workers are productive and raise healthy families. Adequate health insurance is a crucial component to achieving organizational goals, which maintains educators' health to expand and sustain Nigeria's education sector. (1) submit that workers with reduced health risks generally have improved productivity, whereas those with increased health risks experience decreased productivity. When workers are healthy, they tend to work best, unlike when they are unwell and cannot work beyond the basic requirements. When organizations are attentive to workers' health, employees tend to focus more on achieving set deliverables, resulting in higher productivity for both organizations and employees. Well-integrated health enhancement initiatives, including enrolment for health insurance, can improve health status and productivity in the workplace. Educators are direct role models, and their sustainable health would immensely affect the generations to come.
Health insurance literacy is simply knowing and interpreting health plans to suit one's needs. (2) Understanding health insurance is essential to affording and accessing health care in any nation (3). While health literacy has been generally studied and measured, health insurance literacy has not (3). For instance, in the United States of America (USA), the success of federal insurance schemes is partly hinged on consumers' ability to understand health insurance and make informed decisions. Therefore, health insurance literacy is one factor that may determine whether consumers select a suitable health plan and use it to their advantage in all human ecosystems, including Nigeria. There is an urgency to develop better health and health insurance literacy in Nigeria.
The World Health Organization (4) estimates the average male and female life expectancy of Nigerians to be 53.7 and 55.4 years, respectively. Maternal mortality in Nigeria is among the highest globally, accounting for 19% of global maternal deaths, with an estimated infant mortality rate at 19 deaths per 1000 births and mortality among children under five at 128 per 1000 (5). Communicable and infectious diseases are the major health problems in Nigeria (6) (7) (8) (9). As the general population in Nigeria, teachers are primarily exposed to malaria, respiratory infections, high blood pressure, typhoid, and diarrheal diseases. This is aside from the Coronavirus (COVID-19), which is still infecting thousands of Nigerians, with many deaths already recorded. WHO (10) further indicates that high reliance on out-of-pocket health expenditures has persisted despite consensus moves towards universal health coverage (UHC). Improvement of Nigeria's healthcare system is hindered by insufficient public funding, a high infectious disease burden, increased communicable and non-communicable diseases, and high infant and maternal mortality rates. Therefore, an efficient national health insurance model is required in Nigeria to attain UHC to ensure total access to quality healthcare without the risk of impoverishment. Projections by Azuogu et al. (11) highlight that about a hundred million people globally are pushed into poverty due to out-of-pocket expenditures for healthcare services, causing millions of people not to seek healthcare in hospitals since they cannot afford it. Makinde et al. (12) claim that limited funding, lack of leadership support, inadequate capacity-building opportunities and equipment are the major problems in Nigeria's health system.
Sanusi and Awe (13) contend that consumers' inability to pay for health services and inequitable healthcare provision are among the factors responsible for the lack of access to healthcare in Nigeria. Aregbesola (14) relays that since Nigeria's independence in 1960, there has been minimal social protection coverage, with over 90% of the population existing without health insurance. Hence, Nigeria launched the National Health Insurance Scheme (NHIS) in June 2005 to solve inequality in healthcare services and increase healthcare access. The Nigerian medical system has evolved over the years through the National Health Insurance Scheme (NHIS), National Immunization Coverage Scheme (NICS), Midwives Service Scheme (MSS), and Nigerian Pay for Performance Scheme (P4P), all aimed to address public health challenges. Despite government efforts, political instability, corruption, limited institutional capacity, and an unstable economy are major factors responsible for the poor development of health services in Nigeria (14). Therefore, families and individuals are left to bear the burden of a flawed health system, leading to delays, not seeking healthcare, and having to pay out-of-pocket for medical services that are not affordable. Ilesanmi et al. (15) submit that catastrophic health expenditure (CHE) is widespread in Nigeria despite the implementation of the NHIS. Hence, universal health insurance coverage in Nigeria should be fast-tracked to give the expected financial risk protection and decreased CHE incidence. Asakitikpi (16) reveals that healthcare reforms have succeeded in providing medical services for the upper and middle classes and have marginalized the lower level, which constitutes over 75% of the approximately 200 million citizens. The programs that focus on re-equipping government hospitals, ensuring constant power supply, providing foreign drugs and other consumables have mainly benefitted the upper and middle classes because reformation and commercialization of the health facilities result in higher costs of accessing them. Also, the NHIS is predominantly focused on those who work in public and organized private sectors, with the government subsidizing health insurance for employees. Although Community Based Health Insurance (CBHI) schemes through NHIS and state-run health insurance agencies have been introduced in Nigeria, they have generally not succeeded due to poor financial support, inability to meet beneficiaries' needs, unclear legislative frameworks as well as unrealistic enrolment requirements. Odeyemi (17) contends that Nigeria can address the disappointing uptake of CBHI elements by integrating informal and formal programs alongside increased beneficiaries' involvement through improved communication and education and targeted financial assistance.
Many factors impede the uptake of health insurance in the informal sectors in Nigeria. Previous studies on the NHIS record a low level of awareness, unfavorable perception, and minimal enrollment level (18) (19) (20). Azuogu et al. (11) attribute the low participation of individuals in the informal sector to the limited and irregular income and uncertain employment status. Paez et al. (3) further surmise that many people fail to realize the underlying reason that health insurance serves as a hedge against high medical costs. They are unaware of their liability should they become seriously ill. Although Adewole et al. (21) agree that implementing and expanding health insurance in the informal sector is challenging, they suggest that innovative models are needed to enable potential enrollees to better understand and consent to the concept of prepayment methods for private funding of healthcare. Furthermore, Okaro et al. (22) argue that implementing NHIS is hinged on both the awareness and perception of sustaining the program in line with its creation objectives. This partially explains why Adebisi et al. (23) conclude that NHIS has not fully achieved its goals because health insurance resources delivered via unutilized communication channels that by the target population will likely fail to reach the people they intend to serve (Tichenor et al. 1970, cited in (24).
Hitherto, studies have assessed awareness levels, enrollment, and perception of the NHIS in Nigeria among healthcare providers and consumers. However, no research has included private school workers who should form a significant health insurance system population. Investigation reveals that educators are opinion leaders and have a high level of influence in their various communities. Consequently, this study assesses the awareness, perception, and enrolment levels of private school workers in Ibadan, Oyo State, Southwest, Nigeria regarding the National Health Insurance Scheme (NHIS). It aims to bridge the information gap and contribute strategies towards achieving the NHIS objectives.
Theoretical Underpinning
To theoretically anchor this study, we use the Health Belief Model (HBM) and Protection Motivation Theory (PMT) to highlight the fine points that are critical to bridging the information gap in the awareness, perception, and enrollment levels of private school workers towards improving their contributions to the NHIS in Nigeria. The HBM and PMT have received scholarly attention over time, with the latter coming more under severe criticism, reinterpretation, and revision (25). However, we find an alignment between the two theories that are profitable in studying the Nigerian situation. This is ostensible because they both emphasize the importance of people’s attitude and behavioral change in such issues as health insurance literacy and wellness matters in the context of a developing society such as Nigeria. Keeping educators healthy in such an ecosystem with all its challenges could be very complex. Hence, this study used the HBM and PMT to foreground the discussion of issues such as health insurance literacy awareness and actions as they pertain to private school workers in Nigeria.
Health Belief Model
Health Belief Model (HBM) tries to predict human health behaviors. Carpenter (25); Montanaro and Bryan (26) explain that the HBM was initially developed by four American scientists in the 1950s and updated in the 1980s. The model is based on the theory that a person’s willingness to change their health behaviors is primarily due to four factors.
1. Perceived Susceptibility: except where there is an imminent risk, one is unlikely to alter one’s health behaviors (27). For example, more married women of childbearing age are likely to enroll in health insurance than unmarried ones because of the need for antenatal healthcare.
2. Perceived Severity: Janz and Becker (28) claim that the likelihood of whether or not a person will alter their health patterns to avoid a consequence is hinged on how grave they perceive the implication to be. For instance, the breadwinner of a family or someone with higher financial responsibilities is more likely to think of registering for health insurance compared to the person who has fewer responsibilities.
3. Perceived Benefits: persuading people to change behavior can be difficult, especially if they do not see immediate benefits. Humans are reluctant to give up what they enjoy if there is no replacement for it (26). For example, a person will probably not buy health insurance if they are not often sick compared to a frequently ill person. On the other hand, if the less sickly person is promised a rollover or cash return, they would probably enroll for health insurance because there is nothing to lose.
4. Perceived Barriers: one main reason people are reluctant to alter their health patterns is that they think it will be impossible or difficult. Changing health behaviors can be exerting financially and socially (27) (28). For instance, low-income earners are less likely to purchase health insurance (though they may need it more) because they believe that if they take out from their limited resources to buy health insurance, it will affect their ability to provide basic needs.
Health Belief Model realistically helps to frame people’s behaviors, acknowledging that, at times, just wanting to change one’s pattern of payment for healthcare is not enough to make one do so essentially. Furtado et al. (24) reveal that illness may lead the uninsured to seek health information, but it might not prompt them to search for insurance information. Two additional elements are incorporated into the HBM to approximate what it takes to move an individual to action. They are Cues-to-Action and Self-Efficacy. Firstly, Carpenter (25) posits that cues-to-action are both internal and external events that prompt a desire to make a health change. This helps to move someone from wanting to make a health change to making the change. For example, getting a call from a friend who requests to borrow money to offset hospital bills can convince someone who is aware of health insurance but hasn’t enrolled to do so. Also, having high blood pressure symptoms such as heart palpitations or getting involved in a car accident can convince a person to take a health insurance plan.
On the other hand, self-efficacy analyses a person’s conviction in their potential to make health-related adjustments. The belief in one’s ability to execute a task can significantly impact one’s actual capacity to perform the task (29). Believing that one can save up or take a loan to get health insurance despite one’s low-income level can ultimately lead one to get health insurance. It is similar to self-concept or self-perception, where one behaves according to how one perceives themselves. Awosola et al. (30) describe Self-efficacy as part of an individual’s ability to negotiate health adjustments in lifestyle successfully.
Protection Motivation Theory (PMT)
Protection Motivation Theory extends the concepts and links to some of the elements of HBM. PMT establishes how people are inspired to react in a self-protective way towards apparent health-related threats similar to postulations by the HBM.
Rogers (31) formally coined this model to help explain fear appeals. The PMT suggests that people safeguard themselves based on four factors;
(1) The perceived severity of a threatening event;
(2) The perceived probability of the occurrence or vulnerability;
(3) The efficacy of the recommended preventive behavior;
(4) The perceived self-efficacy;
Protection motivation branches from both the threat appraisal and the coping appraisal; while threat appraisal measures the seriousness of the circumstances, coping appraisal refers to how a person responds to it. The coping appraisal constitutes both efficacy and self-efficacy. Efficacy is the anticipation that a person can accomplish a recommendation to remove a threat, whereas self-efficacy is the conviction in oneself to achieve suggested goals (31) effectively. Westcott et al. (32) relay that the diversification of PMT over four decades has been used to explain individual human conduct, families, parent-child interaction, and emergency-relief situations worldwide. Its approach is that prevention is always better than cure.
The ability to transform people's awareness of health insurance into effective preparedness by buying into the NHIS scheme ahead of the pressures of an imminent health risk, the narrower the gap between threat awareness and survival will be. Dynamically applying theory to an investigation, and expanding the outcomes to form hands-on strategies beneficial to the population, could help narrow the awareness-enrollment gap and produce other research possibilities. Maddux and Rogers (33) demonstrate that self-efficacy is "the most powerful predictor of behavioral intentions" preceding actual behavior. Both BHM and PMT's objective is to identify and evaluate the threat and counter this assessment with effective alleviation options. This makes PMT and, by extension, HBM germane to investigating social issues, including awareness, perception, and enrollment levels of private school workers towards health insurance.