Strengthening care for emergencies: what is the level of awareness and utilization of Emergency Medical Services (EMS) in FCT, Nigeria?

TL;DR

This study assesses public awareness and use of emergency medical services in Nigeria's FCT, finding low awareness and utilization with key predictors like age, location, and employment.

Contribution

The study identifies socio-demographic predictors of EMS awareness and utilization in Nigeria, offering insights for improving emergency care access.

Findings

Only 57.8% of respondents are aware of EMS, with most uncertain about the source of information.

Just 8.6% have used EMS via the toll-free line, and males show lower odds of awareness and utilization.

Age, location, and employment status significantly predict EMS awareness and utilization.

Abstract

As part of the Federal Government of Nigeria’s desire to increase medical coverage among the citizenry, the National Emergency Medical Service and Ambulance Scheme (NEMSAS) was set up and piloted in the FCT in 2022. To gauge the progress so far, this study sought to assess the level and determinants of public awareness and utilization of Emergency Medical Services (EMS) among residents of the Federal Capital Territory, Abuja.

A cross-sectional study was conducted in June 2023 among 1177 respondents residing in FCT Abuja at the time of the survey. Data was collected by trained research assistants using an interviewer-administered questionnaire and purposive sampling was adopted. The level of awareness and the socio-demographic determinants of the level of awareness in the FCT were assessed. Logistic regression was used to find predictors of EMS awareness and utilization.

57.8% of respondents are aware of EMS, while 42.2% are not. 62.7% are uncertain about the source of information for EMS with only a minority relying on word of mouth (17.7%), traditional media (11.1%), or social media (8.5%). 91.4% have not accessed or utilized EMS via the toll-free emergency line, while only 8.6% reported doing so. There are median EMS awareness and utilization differences across gender, age, location, and employment status of the respondents. Additionally, the multivariate logistic regression showed that age, location, and employment status are significant predictors of EMS awareness and utilization. Males have lower odds of awareness and utilization of EMS compared to females. Furthermore, there was a significant relationship between EMS access and utilization (Chi-square = 80.748, p < 0.001). However, awareness did not necessarily translate to utilization.

The relationship between EMS awareness and utilization and the unmasked predictors in this paper should be factored into the design of interventions to increase access and utilization of EMS in Nigeria.

The online version contains supplementary material available at 10.1186/s12873-024-00991-2.

Full text

Background

A medical emergency is an acute injury or illness that poses an immediate risk to an individual’s life or long-term health [1]. They range from self-resolving allergic reactions to cardiovascular emergencies and life-threatening injuries [2]. Emergencies contribute significantly to the burden of diseases globally, contributing to 41.7% of morbidities and 50.7% of all mortalities [1]. In Nigeria, medical emergencies range from acute severe malaria to neurological injuries following trauma and contribute to 345 DALYs per 1000 to the burden of diseases in the country [3, 4].

Most emergencies require assistance from a medical service provider, such as emergency medical services [5]. Emergency Medical Service (EMS) is a “comprehensive system that provides the arrangements of personnel, facilities, and equipment for the effective, coordinated, and timely delivery of health and safety services to victims of sudden illness or injury” [6]. EMS aims to provide the first point of contact of urgent medical care to satisfactorily treat the presenting conditions, from the scene of the incidents to the point of definitive care to victims of sudden or life-threatening emergencies [7, 8]. This prevents unwarranted mortality or other preventable bodily infractions [9, 10]. There is a wide spectrum of emergency care services - pre-hospital, hospital, and rehabilitative care and the linkages between the components, including but not limited to emergency personnel, an emergency communication system, emergency infrastructure, an integrated emergency ambulance service system, emergency equipment, and a functional trauma system in the receiving facility [11].

The emergency care system indirectly impacts mortality and morbidity at all levels of society [12, 13]. Hence, emergency care is essential to the health system as it is the first point of contact for many injured, including those in road crashes worldwide [7, 14]. However, timely emergency care is not readily available or prohibitively expensive in some regions of the world [7]. It has been estimated that more than 50% of deaths and more than 30% of disabilities in low- and middle-income countries could be addressed by effective emergency care [15].

The provision of EMS in Nigeria is still nascent after different failed attempts by national and state governments at establishing a comprehensive emergency system in the country. This has resulted in inadequate and often delayed medical care for individuals with medical emergencies [16–18]. Challenges of EMS include a lack of infrastructure, limited resources, and inadequate training [16]. Although improvements in emergency care in Nigeria will involve strengthening human resources, physical resources, and organization and planning for prehospital care and care in hospitals (which are all supply-driven), there is an even greater need to ensure that the citizens are aware of and utilize these supplies when they are available, especially as communication has been noted as a major driver of an effective EMS system [19]. Given this, it is important to understand the level of awareness of the availability of emergency medical services in FCT.

The National Health Act of 2014 made financial provisions to fund EMS in Nigeria to address these challenges and improve the provision of EMS in Nigeria. This led to the creation of the National Emergency Medical Service and Ambulance Scheme (NEMSAS), which is tasked with the responsibility of organizing Emergency Medical Services and Pre-hospital and Emergency care services and ensuring that these services have a sustainable and high-impact service element in Nigeria’s health system architecture. NEMSAS piloted the provision of its services in Nigeria’s Federal Capital Territory (FCT) by leveraging the national emergency call toll line (112) for the provision of EMS to the residents.

We surveyed the residents of Nigeria’s FCT to understand their level of awareness of the availability of EMS. The specific objectives were to:

• i.Assess the level of public awareness and utilization of EMS in FCT.
• ii.Assess the relationship between awareness and utilization of EMS in FCT.
• iii.Predict key determinants of awareness and utilization of EMS using demographic variables.

Methods

Study population and design

This was a cross-sectional study conducted in June 2023 among 1177 residents of FCT, Abuja. The Federal Capital Territory (FCT) is a federal jurisdiction situated in the heart of Nigeria. It is home to Abuja, the nation’s capital city and the seat of government with an estimated population of 3,067,500 persons [20]. The Federal Capital Territory comprises six Area councils: Abaji, Abuja Municipal Area Council (AMAC), Bwari, Gwagwalada, Kuje, and Kwali, collectively covering an area of approximately 7,290 square kilometres [21].

Purposive sampling was used to assess residents’ level of awareness of the availability of EMS using an interviewer-administered questionnaire (included as supplementary material). There were two main reasons for choosing purposive sampling.

• Absence of Census Data: One significant reason for adopting purposive sampling was the absence of reliable census data. The last census in Nigeria was conducted in 2006, making it outdated.
• Specific Criteria: Secondly, purposive sampling allowed researchers to select respondents based on specific criteria relevant to the study objectives. In this case, the criterion was that residents must have been living in the FCT since 2021. This targeted residents who would have had the opportunity to be aware of NEMSAS launched in 2022.

The original sample size of 1300 was obtained and 123 representing 9.5% were excluded because of nonresponse and missing data yielding the final sample size of 1177 that was analyzed. The details of the sample size determination is presented in Table 1 and the population data was obtained from [20].

Table 1. Sample Size DeterminationLocationPopulationInitial Sample SizeFinal Sample SizeAbaji127,9005447AMAC1,693,400717632Bwari500,100212181Gwagwalada346,000147134Kuje212,10090103Kwali188,0008080 Total

3,067,500

1300

1177 AMAC: Abuja Municipal Council

This research used purposive sampling and assigned samples based on the proportion of the projected population of the FCT. This is quite different from quota sampling because the criteria were based on residency in Abuja since 2021. Unlike quota sampling, we are not interested in a sample reflecting the characteristics of the population in terms of certain attributes, such as age, gender, or socioeconomic status.

Research assistants were recruited to survey under the supervision of experts in survey methodology. Kobo Collect was the data management tool used in data collection.

Reliability test and piloting

The contents of the questionnaire was reviewed by two of the co-authors who are experts in survey and monitoring and evaluation. Afterwards, a pilot study was carried out in New Karu Town in Karu local government area of Nasarawa State which shares boundaries with FCT. The area was chosen because majority of the residents worked in the FCT. The limitation of the pilot study was most of the respondents work in AMAC and their views are very similar.

The feedback from the pilot study were reviewed by experts and incorporated into the questionnaire and to ensure that the items adequately cover the construct they intend to measure and are relevant to the research objectives.

Cronbach’s Alpha, which is a measure of reliability, could not be performed because there are very few items, and most are not Likert-scaled.

Variables

The questionnaire was divided into two sections. Section A contains the four demographic variables namely: gender, age, location (the six area councils), and employment status. Section B contains variables that assess the degree of knowledge of EMS. The first variable is to assess if the respondents have been in an emergency and the second one is to gauge their respective responses during emergencies. The third variable is to determine if the respondents are aware of the toll-free emergency line that can be used to utilize the EMS offered. The fourth variable is to determine the source of information about EMS and the fifth variable is to ascertain if the respondents know of anyone that has accessed EMS. The sixth variable contained the type of emergency reported, and the final variable was to determine if the respondents benefited from first aid or basic life-supportive training in the past.

Data analysis

The data was extracted from Kobo Collect and transferred to Microsoft Excel for extensive data cleaning. SPSS (Statistical Package for the Social Sciences) version 27 was used for descriptive statistics, crosstabulation, Chi-square test, Mann-Whitney test, and Logistic regression. R software version 4.3.2 was used for Kruskal-Wallis. A p-value less than 0.05 is considered significant except otherwise stated.

Ethical considerations

Ethical approval was obtained from the National Health Research Ethics Committee (NHREC) with ref number: NREC/01/01/2007-16/05/2023. Informed consent was also obtained from all participants in the study and were duly informed of their inalienable rights to withdraw participation from the study at any point in the study. Additionally, assent was sought and received from participants aged less than 18 years old, while consent was received from their parents and legal guardians.

Results

Demographic analysis

The summary of the demographic characteristics of the respondents is presented in Table 2. 43.1 per cent were female, 35.8% were between 31 and 45 years and 53.7% were interviewed in AMAC and 59.7% were employed.

Table 2. Summary of the demographic variablesVariableFrequencyPercentage Gender Female50743.1Male67056.9 Age 11–1513111.116–3039133.231–4542135.846–6019816.8Above 60363.1 Location Abaji474.0AMAC63253.7Bwari18115.4Gwagwalada13411.4Kuje1038.8Kwali806.8 Employment Student24821.1Unemployed22619.2Employed70359.7

Measures of awareness and other attributes

The survey showed that 80.8% have witnessed or been in emergencies. The data reveals, as shown in Table 3, diverse responses to emergencies, with 33.6% of individuals opting to call for help, 17.2% providing first aid, and 35.3% did nothing in response to the emergency. Some chose to contact family members (8.5%), while a smaller percentage directly called an emergency helpline (4.0%). Additionally, 1.4% of individuals used their smartphones to document or record the situation. 57.8% of respondents in the dataset are aware of EMS, while 42.2% are not. Most respondents (62.7%) are uncertain about the source of information for EMS with only a minority relying on word of mouth (17.7%), traditional media (11.1%), or social media (8.5%). The majority (91.4%) have not accessed or utilized EMS via the toll-free emergency line, while only 8.6% reported doing so. 79.4% have not reported any emergency, 8.8% have reported fire incidents and 7.4% and 4.5% have reported road accidents and medical emergencies respectively.

Table 3. Summary of measures of awareness and other attributesVariableFrequencyPercentage Ever witnessed or been in an emergency No22619.2Yes95180.8 Response to emergency Call for help39533.6Provide first aid20217.2Did nothing41635.3Phone family member1008.5Call the emergency helpline474.0Document or record using a smartphone171.4 Awareness of EMS No49742.2Yes68057.8 Source of Information for EMS Word of mouth20817.7Traditional media13111.1Social media1008.5Don’t know73862.7 Accessed EMS via toll-free emergency line No107691.4Yes1018.6 Type of emergency reported per centFire1038.8Road accident877.4Medical emergency534.5None93479.4 Ever had any form of first aid or basic life-supportive training No81569.2Yes36230.8

Differences in the awareness

Mann-Whitney test (MWT) showed there is a significant median EMS awareness between males and females. The other three analyses as presented in Table 4 were done using the Kruskal-Wallis test (KWT) which showed significant median EMS awareness across age, location, and employment status of the respondents.

Table 4. Demographic Differences in the Awareness LevelVariableNoYesMWT /KWT Gender Female231276159,891Male266404 Age 11–15716024.4816–3015523631–4515726446–6089109Above 602511 Location Abaji242359.63AMAC306326Bwari58123Gwagwalada7064Kuje1786Kwali2258 Employment Student10114724.3Unemployed12898Employed268435P < 0.05: **p < 0.01; MWT = Mann-Whitney Test; KWT = Kruskal-Wallis Test

Predictors of EMS awareness

Binary logistic regression was used to predict EMS awareness using the four demographic variables. The univariate models showed that all four demographic variables are significant predictors of EMS awareness while all, but gender were significant predictors in the multivariate model presented in Table 5.

Table 5. Predictors of EMS AwarenessVariable^1^Univariate modelsMultivariable model^2^Crude OR (95% CI)p-valueCrude OR (95% CI)p-valueGenderFemale10.04410.125Male0.79 (0.62, 0.99)0.82 (0.64, 1.06)Age11–151< 0.0011 0.001 16–301.92 (0.87, 4.22)0.97 (0.40, 2.38)31–453.46 (1.66, 7.24)2.07 (0.94, 4.59)46–603.82 (1.83, 7.98) 2.53 (1.15, 5.57) Above 602.78 (1.30, 5.97)1.88 (0.83, 4.25)LocationAbaji1< 0.0011 < 0.001 AMAC0.36 (0.17, 0.77) 0.36 (0.17, 0.79) Bwari0.40 (0.24, 0.68) 0.38 (0.22, 0.65) Gwagwalada0.80 (0.45, 1.44)0.79 (0.43, 1.44)Kuje0.35 (0.19, 0.63) 0.33 (0.18, 0.62) Kwali1.92 (0.94, 3.92)2.01 (0.97, 4.19)EmploymentStudent< 0.001 < 0.001 Unemployed0.90 (0.67, 1.20)1.23 (0.82, 1.84)Employed0.47 (0.35, 0.64) 0.49 (0.35, 0.68) ^1^The first listed category of each variable was taken as reference value ^2^Following multiple logistic regression, variables significantly associated with EMS awareness are presented in bold

In both models, males have lower odds of being aware of EMS compared to females. Additionally, respondents aged 31 and above have higher odds of awareness compared to those aged between 11 and 15. Those who are employed have lower odds of being aware of EMS compared to students.

Differences in utilizing EMS

Mann-Whitney test (MWT) showed there is a significant median EMS utilization between males and females. The other three analyses as presented in Table 6 were done using the Kruskal-Wallis test (KWT) which showed significant median EMS utilization across age, location, and employment status of the respondents.

Table 6. Demographic Differences in UtilizingEMSVariableNoYesMWT /KWT Gender Female47136165427.5*Male60565 Age 11–15130121.53716–303672431–453754646–6017325Above 60315 Location 45.83Abaji416AMAC58745Bwari1738Gwagwalada1277Kuje7726Kwali719 Employment 17.84**Student2399Unemployed21412Employed62380

Predictors of EMS utilization

Binary logistic regression was used to predict EMS utilization using the four demographic variables. The univariate and multivariate models revealed that all but gender of the demographic variables are significant predictors of EMS awareness as presented in Table 7.

Table 7. Predictors of EMS UtilizationVariable^1^Univariate modelsMultivariable model^2^Crude OR (95% CI)p-valueCrude OR (95% CI)p-valueGenderFemale10.11610.570Male0.71 (0.47, 1.09)0.88 (0.56, 1.37)Age11–1510.0031 0.046 16–30 0.05 (0.01, 0.42)

0.04 (0.00, 0.42) 31–450.41 (0.15, 1.14) 0.26 (0.08, 0.83) 46–600.76 (0.28, 2.05)0.40 (0.13, 1.22)Above 600.90 (0.32, 2.52)0.44 (0.14, 1.38)LocationAbaji1< 0.0011 < 0.001 AMAC1.15 (0.38, 3.48)0.83 (0.27, 2.59)Bwari0.61 (0.28, 1.29) 0.44 (0.20, 0.96) Gwagwalada0.37 (0.14, 0.98) 0.28 (0.10, 0.78) Kuje0.44 (0.16, 1.22) 0.32 (0.11, 0.91) Kwali2.66 (1.17, 6.07)2.12 (0.90, 5.01)EmploymentStudent< 0.001 0.005 Unemployed0.29 (0.15, 0.59)0.52 (0.22, 1.20)Employed0.44 (0.23, 0.82) 0.33 (0.16, 0.66) ^1^The first listed category of each variable was taken as reference value ^2^Following multiple logistic regression, variables significantly associated with EMS Utilization are presented in bold

Relationship between EMS awareness and utilization

The Chi-square test showed a significant relationship between EMS awareness and utilization (Chi-square = 80.748, p < 0.001). The Chi-square was computed from the contingency table and the Fisher test was not carried out since all the expected frequencies are greater than 5, despite reporting a zero in one of the cells of the observed frequency (Table 8).

Table 8. Contingency Table of the relationship between EMS awareness and utilizationEMS utilizationTotalNoYes EMS Awareness No4970497Yes579101680Total10761011177

Discussion

Findings from the study revealed that the awareness of EMS in the FCT is slightly above average. This corroborates with the findings from another study of awareness of EMS in Nigeria which found that less than half of the respondents were aware of any form of emergency medical response in Nigeria [22]. However, this contrasts with the findings of a study that assessed the awareness of emergency response services among users of EMS in FCT and Keffi [21], which showed more than 90% of users of EMS in Abuja were aware of emergency medical response service and emergency call numbers. The differences in the level of awareness and the one previously conducted in the FCT may be due to the difference in our study population composition. This paper surveyed residents as opposed to beneficiaries of EMS.

Within the FCT, there is also significant variation in the level of awareness among the area councils in the FCT. AMAC seems to be doing better in terms of the level of awareness when compared with other area councils. The probable reasons for these variations could be differences in urbanization, population density, level of communication, outreaches done in the area council, and historical emergency incidents in the area council. These factors have been noted as major drivers of awareness of emergency medical services in the literature [14, 22]. The study also found a statistically significant difference in the level of awareness by gender. The finding is in alignment with other studies conducted in Nigeria, which have reported that women are less aware of EMS than men [23]. This finding is unsurprising given the gender disparities in the access to healthcare services in Nigeria [24]. However, our logistic regression predicts that males are less likely to be aware of EMS. Among the different age groups, significant statistical differences exist. More precisely, older age groups are more likely to be aware of EMS compared to the youngest group (11–15). This finding is consistent with the findings of [25] that health literacy is associated with senior citizens as they may be dealing with multiple health challenges that require constant visits to the hospital.

Again, students are more likely to be aware of EMS compared to employed and unemployed individuals since students had a higher odds ratio than both the employed and unemployed participants. This finding is intuitively appealing as students are expected to be more aware because they are often in educational environments where they may come across information about emergency services as part of their curriculum or through educational programs. Again, students may be more connected to various sources of information, including educational materials, news, and online resources, which could increase their awareness of EMS. Furthermore, students might be more active on social media and have a lifestyle that exposes them to a variety of information, including public safety and emergency services, community activities, volunteer work, internships, etc.

From Table 8, among individuals aware of EMS, 14.8% utilized the service, indicating a positive association. Notably, among those without EMS awareness, no instances of utilization were observed. This absence hints at a potential link between awareness and utilization, emphasizing the impact of awareness campaigns on encouraging EMS use. The probable reason for low utilization can be low confidence in the EMS as the low utilization of the primary health care services has been attributed to low confidence [26].

Additionally, the Mann-Whitney test indicates a substantial gender difference, with more males (65) utilizing EMS compared to females (36). This point to a potential gender-related disparity in emergency healthcare-seeking behaviour. This finding deviates from the findings of other studies that have noted the prevalence of healthcare utilization among male users [27, 28]. Hence, our logistic regression predicts that males have lesser odds of utilizing the EMS than their female counterparts.

The Kruskal-Wallis test exposes significant age-related variations, with higher EMS utilization in the age groups 31–45 and 46–60, suggesting that middle-aged individuals are more likely to seek emergency medical assistance. This finding is partially in alignment with other studies that found a positive relationship between healthcare utilization and age [29].

Location-based differences are evident, as the Kruskal-Wallis test highlights varying EMS utilization across different areas. Kuje exhibits the highest utilization, while Abaji and Gwagwalada show comparatively lower usage, indicating potential discrepancies in access or awareness. Different areas had varying odds of EMS utilization, indicating a geographical influence on the likelihood of utilizing EMS services. The probable reason for this can be the nearness of health facilities as proximity has been highlighted as a key determinant for the utilization of healthcare services [30]. The nature of the composition of the population could also be responsible.

Moreover, employment status significantly influences EMS utilization, with employed individuals (80) demonstrating the highest usage, followed by unemployed (12) and students (9). This emphasizes the impact of occupational factors on emergency healthcare-seeking behaviour. Those that are employed are likely to have health insurance or have finances to address any health emergencies. Also the distance travelled for work and prolonged absence from residence as a result of work increases their odds of soliciting for EMS. These findings are in tune with [31] who noted that occupational differences or characteristics of individuals have a significant influence on healthcare service utilization. However, this contrasts with the findings of [32] who reported that the unemployed had higher odds of using formal healthcare facilities than those currently employed. The difference in geographical scope of these studies, urban, compared to the slum can be the probable reason for the variance.

Limitation of study

Our findings may have been affected by social desirability bias as many of our respondents might have answered the questions in a way that they believed was socially acceptable or desirable, rather than reporting their true behaviours. This can happen because people want to avoid appearing uninformed, irresponsible, or in a negative light. Consequently, this can lead to overestimation of the level of awareness in the study. People might also overestimate their knowledge of EMS, especially if they feel they should know more about them. Additionally, it may lead to underreporting of utilization as some people may be reluctant to admit usage of EMS. To mitigate the effect of the limitation, the following strategies were deployed. First, the respondents were given assurances that their responses would remain anonymous and confidential. This helped reduce the fear of judgment, encouraging more honest answers. Second, the research assistants were trained to be neutral and non-judgmental in their interactions with respondents. Lastly, some of the foreseeable issues were addressed after piloting.

Conclusion

The study concluded that the level of awareness and utilization of EMS in FCT is slightly above average, and awareness does not necessarily lead to utilization. The findings from this study have important policy implications. Primarily, there is an evident need for expansive awareness campaigns to enlighten the public about the existence of EMS, with a specific emphasis on promoting the 112 emergency number. Equally, there is a need to drive gender equity in EMS awareness and utilization. Notably, the prominence of word of mouth as an information source emphasizes the importance of maintaining a high degree of responsiveness and quality of care within the EMS system, as positive experiences become a driving force for referrals. In crafting future campaign strategies, it is imperative to consider the diverse awareness landscapes across different area councils. Tailoring communication channels to the specific contexts of each location will be paramount for effective outreach.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1