Knowledge and Attitude Towards the Akwa Ibom State Health Insurance Scheme Among Low-Income Households in Uyo Local Government Area, Akwa Ibom State, Nigeria

Abstract

Background: Low awareness and negative perceptions are major barriers to health insurance uptake, particularly among poor populations. The Akwa Ibom State Health Insurance Scheme (AKSHIS) was established in 2024 to expand coverage, yet the factors determining enrolment among low-income households remain insufficiently understood. This study re-evaluates the knowledge, attitudes, and socioeconomic predictors of AKSHIS enrolment among low-income residents of Uyo Local Government Area (LGA), Nigeria. Methodology: A cross-sectional survey was administered to 406 low-income households in Uyo LGA using systematic multi-stage sampling. To resolve previous classification concerns, household poverty was defined using the per capita Monthly Income compared against the national poverty line. A multivariate logistic regression model was used to isolate the independent effects of knowledge and attitude on enrolment, controlling for age, gender, education, and objective poverty status. Results: Respondents demonstrated sound knowledge of AKSHIS (mean score = 0.744, SD = 0.129), although 22.2% erroneously believed coverage was restricted to civil servants. Attitude scores were highly favorable (mean = 3.99, SD = 0.31), with accessibility of health facilities scoring lowest (mean = 3.78, SD = 0.45). The self-reported enrolment rate was 67.0% (n = 272), which is attributed to localized sampling near accredited facilities and social desirability bias. In the multivariate model, higher knowledge (Adjusted Odds Ratio [aOR] = 31.55, 95% CI: 4.02–247.67, p = 0.001) and positive attitudes (aOR = 2.59, 95% CI: 1.15–5.81, p = 0.021) were strongly associated with higher odds of enrolment. Conversely, living below the national poverty line was associated with reduced enrolment odds (aOR = 0.53, 95% CI: 0.28–1.00, p = 0.052), illustrating that severe financial constraints suppress participation despite adequate awareness. Conclusion: While knowledge and positive attitudes are major drivers of health insurance uptake, direct financial constraints and localized facility accessibility concerns persist. Targeted community-level campaigns addressing eligibility myths and premium guidelines must be accompanied by visible improvements in healthcare quality and subsidized enrollment for the poorest households.