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

Abstract

Introduction: Armed 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. Methods: Data 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. Results: Victimisation 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. 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.