Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey

Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey Adamu Wondimtekahu, Alemayehu Bedassa, Dereje Mengistu, Hilina Faye, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4970275/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study investigates the perceptions of Community-Based Health Insurance (CBHI) holders across various regions and demographic factors in Ethiopia, focusing on their views regarding key aspects of the CBHI program. CBHI initiatives are crucial for enhancing healthcare access and providing financial protection, especially in low- and middle-income countries. In Ethiopia (since 2011), the CBHI program has been part of broader health sector reforms aimed at reducing out-of-pocket (OOP) healthcare expenses and improving service delivery [1]. Method This study employs data from a national customer survey and analyzes responses from CBHI members, who rated aspects such as registration, contribution rates, service efficiency, and travel costs on a five-point Likert scale. This national survey employed a correctional study design and a questionnaire as a data collection tool. Descriptive statistics, chi-square tests, and composite variable scoring were used to interpret the data. Result the Key findings reveal a strong positive perception of the registration process, with 91% of respondents viewing it favorably and 88% finding the contribution rates fair. These elements are crucial for member retention and the sustainability of the CBHI scheme. However, only 75% of the respondents were satisfied with the convenience of services provided under the CBHI, indicating significant areas for improvement, particularly in terms of the efficiency and quality of healthcare services. The study also highlights substantial regional differences, with Dire Dawa showing the highest positive perceptions and Benishangul Gumuz the lowest. Additionally, factors such as age, employment status, duration of CBHI membership, healthcare usage, residence, and awareness level significantly influenced members' perceptions. Conclusion and Recommendation: The findings underscore the need to address region-specific challenges and demographic disparities within the CBHI program. While highly positive perceptions of registration and contribution fairness are encouraging, less favorable views of service convenience and regional disparities suggest uneven program implementation. To improve CBHI effectiveness, policymakers should focus on enhancing service convenience, particularly in regions with higher negative perceptions, through better resource allocation, staff training, and infrastructure improvements. Addressing demographic disparities, particularly among rural populations, younger age groups, and lower-income households, is also essential. Future research should explore these disparities further and evaluate the long-term impact of the CBHI on healthcare access and financial protection. Figures Figure 1 Figure 2 Figure 3 Introduction Community- based health insurance (CBHI) schemes have emerged as pivotal instruments for providing financial protection and improving access to healthcare services in low- and middle-income countries (LMICs) [1]. Unlike formal health insurance systems, which often cover urban and formal sector employees, CBHI schemes are tailored to meet the needs of rural populations and informal sector workers, who are typically underserved by traditional health insurance mechanisms [2]. The primary goal of CBHI programs is to reduce out-of-pocket (OOP) healthcare expenditures, thus preventing impoverishment due to catastrophic health expenses and promoting equity in health service utilization [3]. Despite the growing implementation of CBHI schemes, there remains a significant need to understand the perceptions and satisfaction levels of members, as these are critical indicators of program success and sustainability. Positive member perceptions are essential for high enrollment rates, continuous membership renewal, and overall program viability. Conversely, negative perceptions can lead to low enrollment rates, high dropout rates, and eventual program failure [4]. As shown in a study in Tanzania, household perceptions significantly influence enrollment decisions, with factors such as convenience, healthcare quality, alternative strategies, and knowledge being the most impactful [4]. Similarly, in Ghana, perceptions of quality healthcare services were found to be a key determinant of member satisfaction, with over half of the respondents having a positive perception [5]. In Western Ethiopia, perceptions regarding health status, premium affordability, and care quality are strongly associated with CBHI enrollment [7]. In addition, a study in the Gedio zone highlighted that members with positive perceptions of healthcare quality and favorable attitudes toward the CBHI scheme were much more likely to renew their memberships [8]. This study aims to fill the evidence gap in the area by providing a detailed analysis of CBHI member perceptions in Ethiopia. By examining perception items such as the registration process, contribution fairness, service efficiency, travel time and costs, and trust in CBHI workers and officials, this study seeks to identify key areas of strength and potential improvement. Furthermore, the study explores how these perceptions vary by region, urban versus rural setting, and demographic factors such as age, sex, and membership type (paying vs. indigent). The insights gained from this study are intended to inform policymakers and program administrators about the factors that influence member satisfaction and to guide targeted interventions aimed at enhancing the effectiveness and sustainability of CBHI programs. By addressing region-specific challenges and demographic disparities, the goal is to ensure that CBHI schemes effectively meet the healthcare needs of all members, thereby contributing to the broader objectives of universal health coverage and health equity. Methodology Study Design This study used data from 4008 CBHI members extracted from a national customer satisfaction survey conducted in 2023. The survey used a cross-sectional design with quantitative data collection techniques. The survey identified study participants using 14 strata and by applying random sampling techniques. The tool used for data collection involved a structured questionnaire administered to CBHI members. Participants The national customer survey sample comprised CBHI members from various regions in Ethiopia and was selected through a stratified random sampling method to ensure representation across different demographic groups and geographic locations. The target population included both paying and indigent members to capture a broad spectrum of experiences and perceptions. Data collection The data collected via a national survey through a structured questionnaire included perception items on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The questionnaire covered key aspects of the CBHI program, including the following Registration Process: Assessing the ease and accessibility of CBHI registration. Contribution fairness: Evaluating members' perceptions of the fairness of contribution rates. Out-of-Pocket (OOP) Expenses: Measuring the perceived effectiveness of CBHI in reducing OOP healthcare costs. Service Efficiency: Gauging satisfaction with the efficiency and quality of healthcare services provided under the CBHI, which usually affects perceptions. Travel Time and Costs: Assessing the burden of travel time and costs associated with accessing healthcare services. Trust in CBHI Officials: Evaluating the level of trust in CBHI workers and officials. Data analysis The data were analyzed via descriptive statistics, chi-square tests, and composite variable scoring. Perception levels were categorized as favorable or unfavorable based on scores above or below the mean value of the composite variable. Regional differences and demographic associations were examined via statistical tests to identify significant variations and trends. Results The CBHI members’ perception level is measured via a composite variable created by summing the individual scores of the participants on a five-point Likert scale across the nine perception items. The value of the composite variable is a maximum of 45 and a minimum of 9 for each participant. Hence, the mean value of the composite variable was found to be 35.35 (adjusted for sampling weight) and was used to categorize the participants into two groups. Study participants with individual scores above the mean value of the composite variable were labeled as having a “positive perception”, whereas those below the mean value were labeled as having a “negative perception”. Accordingly, 58.1% of the CBHI members scored above the mean value and were considered to have a “positive or favorable perception”, whereas the remaining participants (41.9%) scored below the mean value and were considered to have a “negative or unfavorable perception”. The combined responses of "agree" and "strongly agree" for each perception item, as illustrated in Fig. 2 , were the highest perception reported for the suitability of the CBHI registration process (91%), followed by the fairness of contribution rates (88%) and the potential for reducing out-of-pocket (OOP) expenses (86%). The favorability of the perception of travel cost was the lowest at 75%. These findings indicate that while members appreciate the ease of enrollment and equitable contribution requirements, there are complaints regarding the efficiency of service delivery. Predictors of perception The multivariate analysis revealed that the perceptions of members toward the CBHI program are significantly influenced by factors such as the age of the participants, employment status, duration of CBHI membership, ever use of health services, residence and level of awareness. Age of the participants Older age groups were significantly more likely to have positive perceptions than younger (18–29 years) participants were. Members who were 66 years and above were 1.91 times more likely to have a positive perception than the youngest, with a significant value of P < 0.05. This may suggest that older members are usually exposed to diseases, mainly chronic cases, and could drive them to value the financial risk protection and improved access to healthcare that the CBHI program provides. Employment Compared with self-employed individuals, those employed by others (66.9%) are 1.56 times more likely to have favorable perceptions of the CBHI program. Students, unemployed individuals, and homemakers are more likely to have positive perceptions than self-employed individuals are, with a significant P value < 0.05. Duration of CBHI Membership Participants with more than 3 years of CBHI membership duration are less likely to perceive positive CBHI membership duration than those with less than 3 years of membership duration, which is statistically significant, with a p value < 0.05. This suggests that over time, some members may become dissatisfied with aspects of the program or encounter challenges that reduce their positive perception. Ever use of health services Participants who had ever utilized their CBHI membership to access healthcare services (58.9%) reported 1.6 times more favorable perceptions than never did. This underlines the importance of program usage in shaping perceptions, which are strongly associated with a statistically significant p value of 0.000. Awareness level of the participants Participants with good awareness had more positive perceptions than did those with poor awareness, with statistically significant p values < 0.005 and ORs of 1.138. Enhancing community-level awareness and understanding of the program's benefits may therefore be an important strategy. Residence Urban residents (60.6%) were more likely to have positive perceptions of the CBHI program than rural residents were, with a significant p value (0.003) and an odds ratio (OR) of 1.203, which may indicate that urban residents are more prone to chronic diseases such as hyperattention and diabetes. Other Factors Demographic Factors The proportion of members with a positive perception differed by region (Fig. 3 ), type of membership (paying vs. indigent), sex, and age group. There was a significant association between age and perception level (Χ2 = 12.7, p = 0.005) and between perception level and renewal decision (Χ2 = 87.527, p = 0.000). These associations suggest that demographic factors play a critical role in shaping members' attitudes toward the CBHI program. Regional differences The perception levels of CBHI members significantly vary across regions (Fig. 3 ). Dire Dawa scored the highest for reducing OOP expenses (93.3%), whereas Benishangul Gumuz scored the lowest (77.2%) for this perception item. The perception of relief from unexpected health expenditures was highest in Dire Dawa (94%) and lowest in SWEP (73%). Trust in CBHI workers and officials varied widely, with high levels of trust reported in Oromia, Addis Ababa, Dire Dawa, and Harari (90–97%) and low levels of trust reported in Amhara and Benishangul-Gumuz (75%). These regional differences suggest that localized factors significantly impact members' perceptions and experiences with the CBHI program. Educational Status Illiterate The findings show that participants with higher education levels have more positive perceptions, ranging from 57.2% with primary education to 64.4% with diploma and above, with an OR of 1.35. Accessibility and Affordability . The affordability of contributions compared with income was perceived positively in regions such as Dire Dawa (93.7%) and Harari (96.2%) but less favorably in Addis Ababa (64.1%) and SWEP (82%). This finding indicates that geographical disparities influence how members perceive the cost and accessibility of healthcare under the CBHI scheme. In general, CBHI members with good awareness, living in urban areas, being older, having a higher education level, and being employed are more likely to have positive perceptions that drive participants toward continuation and a willingness for renewal. Discussion The findings highlight significant regional and demographic variations in the perceptions of CBHI programs. Positive perceptions are associated with better perceived accessibility, affordability, and trust in CBHI workers. The high levels of satisfaction with the registration process and fairness of contribution rates suggest that the CBHI program is well structured in these aspects. However, the lower perceptions of service efficiency and travel costs indicate areas needing improvement. The marked regional differences in perceptions underscore the importance of context-specific interventions. For example, the high perception scores in Dire Dawa may be attributed to better healthcare infrastructure and administrative efficiency, whereas the lower scores in Benishangul Gumuz and Gambella could reflect logistical and infrastructural challenges. The significant associations between perception levels and demographic factors, such as age and renewal decisions, indicate that older and middle-aged members tend to have more favorable perceptions. Urban members were generally more satisfied with the program than their rural counterparts were, with a significant difference in perception levels. The greater positive perception of older and urban residents may be associated with and derived from their greater risk of disease, mostly chronic. The higher renewal rates among members with positive perceptions of ever-used health services emphasize the importance of maintaining trust and improving service quality to ensure sustained membership. Household income was positively associated with satisfaction, with higher-income households reporting better perceptions of the registration process and fairness of contribution rates. Conclusion The pronounced regional disparities in perception levels underscore the importance of tailoring the CBHI program's implementation to the specific needs and challenges of different regions. For example, regions with lower satisfaction levels may require additional support in terms of resources and capacity building to enhance the effectiveness of the program. Furthermore, the significant variation in trust among CBHI officials suggests that efforts to improve transparency, communication, and accountability could enhance member satisfaction and trust in the program. These findings are consistent with those of previous studies that emphasized the importance of good governance and member engagement in the success of CBHI schemes. The findings of this study have important implications for policymakers and program administrators. To increase the overall effectiveness of the CBHI program, targeted strategies should be developed to address specific regional challenges and demographic disparities. Improvements in service efficiency, reductions in travel costs, and increased trust in CBHI officials are critical areas for intervention. By addressing these issues, the CBHI program can better meet the healthcare needs of its members, thereby contributing to the broader goals of universal health coverage and health equity. Future research could further explore the impact of demographic factors on CBHI perceptions and investigate the long-term outcomes of the program in terms of healthcare access, financial protection, and health outcomes. Additionally, longitudinal studies could provide insights into how member perceptions evolve over time and how changes in program implementation affect satisfaction levels. Such research would be valuable in informing ongoing efforts to refine and scale up the CBHI program in Ethiopia and other low- and middle-income countries Abbreviations CBHI Community-based health insurance LMICs Low- and middle-income countries NCS National Customer Satisfaction Survey OOP Out-of-Pocket OR Odds ratio SWEP Southwest Ethiopia people Declarations Consent and ethical considerations The study was conducted in accordance with ethical guidelines and approved by the relevant institutional review boards. Informed consent was obtained from all participants, and confidentiality and anonymity were maintained throughout the research process. The authors have full authority for the publication Competing interests: No competing interest Funding: The study was financially supported by the Ethiopian health insurance service, but the authors declare that they have no conflicts of interest for publication. Author Contribution Adamu Wondimtekahu, Hilina Faye, Wudalew Meselu, Teklu Debebe, Alemayehu Bedassa, Bereket Habte, Geremew Tesgera, Tigist Yoseph, and Kidist Dereje played pivotal roles in the initial stages of the project, contributing significantly to the proposal preparation. They were also deeply involved in the data collection and analysis, ensuring that the research was conducted rigorously and accurately. Their efforts laid a strong foundation for the subsequent phases of the study.Dereje Mengistu, Wodaje Gietaneh, Adamtachew Beyene, Mekonen Ararso, and Fikru Teshome took the lead in the critical task of analyzing the collected data. They meticulously examined the data, drawing meaningful insights that were essential for the report. Additionally, they were responsible for drafting the report, translating the data analysis into a coherent and comprehensive document that effectively communicated the study’s findings.Yamerot Andualem, Frehiwot Abebe, and Muluken Aragaw provided overall leadership and guidance throughout the entire project. From the inception of the proposal to the final dissemination of the results, they ensured that all activities were conducted smoothly and aligned with the project’s objectives. Their leadership was instrumental in coordinating the team’s efforts, maintaining the project’s focus, and ensuring the successful completion of all stages, culminating in the effective sharing of the study’s outcomes with relevant stakeholders. Acknowledgments: The authors would like to express our sincere gratitude to all those who contributed to the completion of this research. First and foremost, we extend our heartfelt thanks to the EHIS management and technical working groups (TWGs) assigned for this work, whose guidance, insights, and unwavering support have been invaluable throughout this journey. We are particularly grateful for their patience and encouragement, which have been instrumental in shaping this work. Availability of data and materials: The authors confirm the availability of full data and material. References Ethiopian Health Insurance Service. Annual Performance Report. 2023 (2015 Ethiopian Fiscal Year). WHO), World Health Organization. Community Based Health Insurance, Key Facts. https://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-2020. 2020. Abebe Sorsa Badacho, Kora Tushune, Yohannes Ejigu, and Tezera Moshago Berheto,. Household Satisfaction with a community-based health insurance scheme in Ethiopia. BMC Research Notes: DOI 10.1186/s13104-016-2226-9. 2016. Do household perceptions influence enrollment decisions into community-based health insurance schemes in Tanzania? Alphoncina Kagaigai, Amani Anaeli, Amani Thomas Mori and Sverre Grepperud. Tanzania : s.n., 2021. Utilization of the Ghana National Health Insurance Scheme and its association with patient perceptions on healthcare quality. HAW, NEL JASON L. Ghana : s.n., 2018 Mebratie A.D. et al. Impact of Ethiopian Pilot Community-Based Health Insurance Scheme on Health-Care Utilization: A Household Panel Data Analysis. The Lancet Global Health, 3(3). 2015 Derseh A, Sparrow R, Debebe ZY, Alemu G, Bedilu B, Mekonnen Y. [Online] 2018 Community‐Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia - Kaso - 2022 - Journal of Environmental and Public Health - Wiley Online Library Tables Table 1 Renewal Decision of CBHI Members by Perception Status in 2023 Renewal Decision Perception Status Total Negative Perception Positive Perception Yes 1650 (40.4%) 2434 (59.6%) 4084 No 136 (75.6%) 44 (24.4%) 180 Table 2 Results of the bivariate analysis of factors influencing the level of perception of the CBHI program Perception Items Category Positive Perception P Value COR 95% C.I. for EXP(B) AOR 95% C.I for EXP (B) P value Lower Upper Lower Upper Residence Rural 56.1% Urban 60.6% 0.003 1.203 1.06 1.35 Age 18–29 53.6% 0.005 0.00 30–49 59.0% 0.02 1.245 1.03 1.49 1.36 1.126 1.654 0.00 50–65 56.7% 0.225 1.134 0.92 1.38 1.30 1.056 1.619 0.01 66 and above 65.1% 0.001 1.613 1.21 2.14 1.91 1.414 2.59 0.00 Educational Status Illiterate 57.2% 0.299 Writ Read Primary 57.8% 0.735 1.025 0.88 1.18 Secondary TVET 58.7% 0.497 1.063 0.89 1.26 Diploma & Above 64.4% 0.062 1.351 0.98 1.85 Sex Male 58.3% Female 57.9% 0.818 0.986 0.87 1.11 Family Size 0–4 58.1% 0.236 5–7 59.1% 0.588 1.038 0.90 1.18 8 and above 55.5% 0.231 0.897 0.75 1.07 Marital Status Married 58.7% 0.038 0.00 Single 63.6% 0.269 1.228 0.85 1.76 1.27 0.864 1.877 0.22 Divorced or Widow 54.0% 0.026 0.826 0.69 0.97 0.72 0.602 0.864 0.00 Employment status Self employed 55.6% 0.00 0.00 Employed by others 66.9% 0.00 1.611 1.32 1.95 1.59 1.295 1.967 0.00 Housewife 59.9% 0.06 1.193 0.99 1.43 1.20 0.999 1.455 0.05 Student & No job 62.1% 0.019 1.309 1.04 1.64 1.29 1.008 1.654 0.04 Duration of CBHI membership 3 years 54.6% 0.008 0.828 0.72 0.95 0.79 0.689 0.922 0.00 Membership type Paying Member 57.8% Indigent 60.8% 0.219 1.13 0.93 1.37 Ever used health service No 47.0% Yes 58.9% 0.00 0.621 0.48 0.79 1.62 1.261 2.08 0.00 Overall Awareness Poor Awareness 56.0% Good Awareness 59.2% 0.047 1.138 1.00 1.29 1.14 1.006 1.307 0.04 Additional Declarations No competing interests reported. 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08:05:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28110,"visible":true,"origin":"","legend":"\u003cp\u003eLevel of Perception (Strongly Agree + Agree) by perception items in Ethiopia in 2023\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4970275/v1/f3396a1acd36af18c54f2531.png"},{"id":65155557,"identity":"21b969e4-e8fc-428d-80d0-4d31ae98a584","added_by":"auto","created_at":"2024-09-24 08:05:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":18070,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of Respondents with favorable Perception toward CBHI Program by Region in 2023\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4970275/v1/946ea58ff41b9ae04fa999bf.png"},{"id":89264509,"identity":"9ee0bb2e-bf9f-4968-9831-b470efa3c0f5","added_by":"auto","created_at":"2025-08-18 07:47:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":909744,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4970275/v1/47b06557-0aff-4b6c-9a24-82f4123b7769.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePerception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCommunity- based health insurance (CBHI) schemes have emerged as pivotal instruments for providing financial protection and improving access to healthcare services in low- and middle-income countries (LMICs) [1]. Unlike formal health insurance systems, which often cover urban and formal sector employees, CBHI schemes are tailored to meet the needs of rural populations and informal sector workers, who are typically underserved by traditional health insurance mechanisms [2]. The primary goal of CBHI programs is to reduce out-of-pocket (OOP) healthcare expenditures, thus preventing impoverishment due to catastrophic health expenses and promoting equity in health service utilization [3].\u003c/p\u003e \u003cp\u003eDespite the growing implementation of CBHI schemes, there remains a significant need to understand the perceptions and satisfaction levels of members, as these are critical indicators of program success and sustainability. Positive member perceptions are essential for high enrollment rates, continuous membership renewal, and overall program viability. Conversely, negative perceptions can lead to low enrollment rates, high dropout rates, and eventual program failure [4]. As shown in a study in Tanzania, household perceptions significantly influence enrollment decisions, with factors such as convenience, healthcare quality, alternative strategies, and knowledge being the most impactful [4]. Similarly, in Ghana, perceptions of quality healthcare services were found to be a key determinant of member satisfaction, with over half of the respondents having a positive perception [5]. In Western Ethiopia, perceptions regarding health status, premium affordability, and care quality are strongly associated with CBHI enrollment [7]. In addition, a study in the Gedio zone highlighted that members with positive perceptions of healthcare quality and favorable attitudes toward the CBHI scheme were much more likely to renew their memberships [8].\u003c/p\u003e \u003cp\u003eThis study aims to fill the evidence gap in the area by providing a detailed analysis of CBHI member perceptions in Ethiopia. By examining perception items such as the registration process, contribution fairness, service efficiency, travel time and costs, and trust in CBHI workers and officials, this study seeks to identify key areas of strength and potential improvement. Furthermore, the study explores how these perceptions vary by region, urban versus rural setting, and demographic factors such as age, sex, and membership type (paying vs. indigent).\u003c/p\u003e \u003cp\u003eThe insights gained from this study are intended to inform policymakers and program administrators about the factors that influence member satisfaction and to guide targeted interventions aimed at enhancing the effectiveness and sustainability of CBHI programs. By addressing region-specific challenges and demographic disparities, the goal is to ensure that CBHI schemes effectively meet the healthcare needs of all members, thereby contributing to the broader objectives of universal health coverage and health equity.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e \u003cstrong\u003eStudy Design\u003c/strong\u003e \u003cp\u003eThis study used data from 4008 CBHI members extracted from a national customer satisfaction survey conducted in 2023. The survey used a cross-sectional design with quantitative data collection techniques. The survey identified study participants using 14 strata and by applying random sampling techniques. The tool used for data collection involved a structured questionnaire administered to CBHI members.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eParticipants\u003c/strong\u003e \u003cp\u003eThe national customer survey sample comprised CBHI members from various regions in Ethiopia and was selected through a stratified random sampling method to ensure representation across different demographic groups and geographic locations. The target population included both paying and indigent members to capture a broad spectrum of experiences and perceptions.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData collection\u003c/strong\u003e \u003cp\u003eThe data collected via a national survey through a structured questionnaire included perception items on a five-point Likert scale ranging from \"strongly disagree\" to \"strongly agree.\" The questionnaire covered key aspects of the CBHI program, including the following\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eRegistration Process: Assessing the ease and accessibility of CBHI registration.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eContribution fairness: Evaluating members' perceptions of the fairness of contribution rates.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOut-of-Pocket (OOP) Expenses: Measuring the perceived effectiveness of CBHI in reducing OOP healthcare costs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eService Efficiency: Gauging satisfaction with the efficiency and quality of healthcare services provided under the CBHI, which usually affects perceptions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTravel Time and Costs: Assessing the burden of travel time and costs associated with accessing healthcare services.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTrust in CBHI Officials: Evaluating the level of trust in CBHI workers and officials.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData analysis\u003c/strong\u003e \u003cp\u003eThe data were analyzed via descriptive statistics, chi-square tests, and composite variable scoring. Perception levels were categorized as favorable or unfavorable based on scores above or below the mean value of the composite variable. Regional differences and demographic associations were examined via statistical tests to identify significant variations and trends.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eThe\u003c/b\u003e CBHI members\u0026rsquo; perception level is measured via a composite variable created by summing the individual scores of the participants on a five-point Likert scale across the nine perception items. The value of the composite variable is a maximum of 45 and a minimum of 9 for each participant. Hence, the mean value of the composite variable was found to be 35.35 (adjusted for sampling weight) and was used to categorize the participants into two groups. Study participants with individual scores above the mean value of the composite variable were labeled as having a \u0026ldquo;positive perception\u0026rdquo;, whereas those below the mean value were labeled as having a \u0026ldquo;negative perception\u0026rdquo;. Accordingly, 58.1% of the CBHI members scored above the mean value and were considered to have a \u0026ldquo;positive or favorable perception\u0026rdquo;, whereas the remaining participants (41.9%) scored below the mean value and were considered to have a \u0026ldquo;negative or unfavorable perception\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe combined responses of \"agree\" and \"strongly agree\" for each perception item, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e, were the highest perception reported for the suitability of the CBHI registration process (91%), followed by the fairness of contribution rates (88%) and the potential for reducing out-of-pocket (OOP) expenses (86%). The favorability of the perception of travel cost was the lowest at 75%. These findings indicate that while members appreciate the ease of enrollment and equitable contribution requirements, there are complaints regarding the efficiency of service delivery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of perception\u003c/h2\u003e \u003cp\u003eThe multivariate analysis revealed that the perceptions of members toward the CBHI program are significantly influenced by factors such as the age of the participants, employment status, duration of CBHI membership, ever use of health services, residence and level of awareness.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAge of the participants\u003c/strong\u003e \u003cp\u003eOlder age groups were significantly more likely to have positive perceptions than younger (18\u0026ndash;29 years) participants were. Members who were 66 years and above were 1.91 times more likely to have a positive perception than the youngest, with a significant value of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. This may suggest that older members are usually exposed to diseases, mainly chronic cases, and could drive them to value the financial risk protection and improved access to healthcare that the CBHI program provides.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEmployment\u003c/strong\u003e \u003cp\u003eCompared with self-employed individuals, those employed by others (66.9%) are 1.56 times more likely to have favorable perceptions of the CBHI program. Students, unemployed individuals, and homemakers are more likely to have positive perceptions than self-employed individuals are, with a significant P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDuration of CBHI Membership\u003c/strong\u003e \u003cp\u003eParticipants with more than 3 years of CBHI membership duration are less likely to perceive positive CBHI membership duration than those with less than 3 years of membership duration, which is statistically significant, with a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. This suggests that over time, some members may become dissatisfied with aspects of the program or encounter challenges that reduce their positive perception.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEver use of health services\u003c/strong\u003e \u003cp\u003eParticipants who had ever utilized their CBHI membership to access healthcare services (58.9%) reported 1.6 times more favorable perceptions than never did. This underlines the importance of program usage in shaping perceptions, which are strongly associated with a statistically significant p value of 0.000.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAwareness level of the participants\u003c/strong\u003e \u003cp\u003eParticipants with good awareness had more positive perceptions than did those with poor awareness, with statistically significant p values\u0026thinsp;\u0026lt;\u0026thinsp;0.005 and ORs of 1.138. Enhancing community-level awareness and understanding of the program's benefits may therefore be an important strategy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eResidence\u003c/strong\u003e \u003cp\u003eUrban residents (60.6%) were more likely to have positive perceptions of the CBHI program than rural residents were, with a significant p value (0.003) and an odds ratio (OR) of 1.203, which may indicate that urban residents are more prone to chronic diseases such as hyperattention and diabetes.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOther Factors\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eDemographic Factors\u003c/strong\u003e \u003cp\u003eThe proportion of members with a positive perception differed by region (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e), type of membership (paying vs. indigent), sex, and age group. There was a significant association between age and perception level (Χ2\u0026thinsp;=\u0026thinsp;12.7, p\u0026thinsp;=\u0026thinsp;0.005) and between perception level and renewal decision (Χ2\u0026thinsp;=\u0026thinsp;87.527, p\u0026thinsp;=\u0026thinsp;0.000). These associations suggest that demographic factors play a critical role in shaping members' attitudes toward the CBHI program.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRegional differences\u003c/strong\u003e \u003cp\u003eThe perception levels of CBHI members significantly vary across regions (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Dire Dawa scored the highest for reducing OOP expenses (93.3%), whereas Benishangul Gumuz scored the lowest (77.2%) for this perception item. The perception of relief from unexpected health expenditures was highest in Dire Dawa (94%) and lowest in SWEP (73%). Trust in CBHI workers and officials varied widely, with high levels of trust reported in Oromia, Addis Ababa, Dire Dawa, and Harari (90\u0026ndash;97%) and low levels of trust reported in Amhara and Benishangul-Gumuz (75%). These regional differences suggest that localized factors significantly impact members' perceptions and experiences with the CBHI program.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEducational Status Illiterate\u003c/strong\u003e \u003cp\u003eThe findings show that participants with higher education levels have more positive perceptions, ranging from 57.2% with primary education to 64.4% with diploma and above, with an OR of 1.35.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAccessibility and Affordability\u003c/b\u003e. The affordability of contributions compared with income was perceived positively in regions such as Dire Dawa (93.7%) and Harari (96.2%) but less favorably in Addis Ababa (64.1%) and SWEP (82%). This finding indicates that geographical disparities influence how members perceive the cost and accessibility of healthcare under the CBHI scheme.\u003c/p\u003e \u003cp\u003eIn general, CBHI members with good awareness, living in urban areas, being older, having a higher education level, and being employed are more likely to have positive perceptions that drive participants toward continuation and a willingness for renewal.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings highlight significant regional and demographic variations in the perceptions of CBHI programs. Positive perceptions are associated with better perceived accessibility, affordability, and trust in CBHI workers. The high levels of satisfaction with the registration process and fairness of contribution rates suggest that the CBHI program is well structured in these aspects. However, the lower perceptions of service efficiency and travel costs indicate areas needing improvement.\u003c/p\u003e \u003cp\u003eThe marked regional differences in perceptions underscore the importance of context-specific interventions. For example, the high perception scores in Dire Dawa may be attributed to better healthcare infrastructure and administrative efficiency, whereas the lower scores in Benishangul Gumuz and Gambella could reflect logistical and infrastructural challenges.\u003c/p\u003e \u003cp\u003eThe significant associations between perception levels and demographic factors, such as age and renewal decisions, indicate that older and middle-aged members tend to have more favorable perceptions. Urban members were generally more satisfied with the program than their rural counterparts were, with a significant difference in perception levels. The greater positive perception of older and urban residents may be associated with and derived from their greater risk of disease, mostly chronic. The higher renewal rates among members with positive perceptions of ever-used health services emphasize the importance of maintaining trust and improving service quality to ensure sustained membership. Household income was positively associated with satisfaction, with higher-income households reporting better perceptions of the registration process and fairness of contribution rates.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe pronounced regional disparities in perception levels underscore the importance of tailoring the CBHI program's implementation to the specific needs and challenges of different regions. For example, regions with lower satisfaction levels may require additional support in terms of resources and capacity building to enhance the effectiveness of the program. Furthermore, the significant variation in trust among CBHI officials suggests that efforts to improve transparency, communication, and accountability could enhance member satisfaction and trust in the program. These findings are consistent with those of previous studies that emphasized the importance of good governance and member engagement in the success of CBHI schemes.\u003c/p\u003e \u003cp\u003eThe findings of this study have important implications for policymakers and program administrators. To increase the overall effectiveness of the CBHI program, targeted strategies should be developed to address specific regional challenges and demographic disparities. Improvements in service efficiency, reductions in travel costs, and increased trust in CBHI officials are critical areas for intervention. By addressing these issues, the CBHI program can better meet the healthcare needs of its members, thereby contributing to the broader goals of universal health coverage and health equity.\u003c/p\u003e \u003cp\u003eFuture research could further explore the impact of demographic factors on CBHI perceptions and investigate the long-term outcomes of the program in terms of healthcare access, financial protection, and health outcomes. Additionally, longitudinal studies could provide insights into how member perceptions evolve over time and how changes in program implementation affect satisfaction levels. Such research would be valuable in informing ongoing efforts to refine and scale up the CBHI program in Ethiopia and other low- and middle-income countries\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity-based health insurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Customer Satisfaction Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOut-of-Pocket\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSWEP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouthwest Ethiopia people\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConsent and ethical considerations\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with ethical guidelines and approved by the relevant institutional review boards. Informed consent was obtained from all participants, and confidentiality and anonymity were maintained throughout the research process. The authors have full authority for the publication\u003c/p\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eNo competing interest\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe study was financially supported by the Ethiopian health insurance service, but the authors declare that they have no conflicts of interest for publication.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAdamu Wondimtekahu, Hilina Faye, Wudalew Meselu, Teklu Debebe, Alemayehu Bedassa, Bereket Habte, Geremew Tesgera, Tigist Yoseph, and Kidist Dereje played pivotal roles in the initial stages of the project, contributing significantly to the proposal preparation. They were also deeply involved in the data collection and analysis, ensuring that the research was conducted rigorously and accurately. Their efforts laid a strong foundation for the subsequent phases of the study.Dereje Mengistu, Wodaje Gietaneh, Adamtachew Beyene, Mekonen Ararso, and Fikru Teshome took the lead in the critical task of analyzing the collected data. They meticulously examined the data, drawing meaningful insights that were essential for the report. Additionally, they were responsible for drafting the report, translating the data analysis into a coherent and comprehensive document that effectively communicated the study\u0026rsquo;s findings.Yamerot Andualem, Frehiwot Abebe, and Muluken Aragaw provided overall leadership and guidance throughout the entire project. From the inception of the proposal to the final dissemination of the results, they ensured that all activities were conducted smoothly and aligned with the project\u0026rsquo;s objectives. Their leadership was instrumental in coordinating the team\u0026rsquo;s efforts, maintaining the project\u0026rsquo;s focus, and ensuring the successful completion of all stages, culminating in the effective sharing of the study\u0026rsquo;s outcomes with relevant stakeholders.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003eThe authors would like to express our sincere gratitude to all those who contributed to the completion of this research. First and foremost, we extend our heartfelt thanks to the EHIS management and technical working groups (TWGs) assigned for this work, whose guidance, insights, and unwavering support have been invaluable throughout this journey. We are particularly grateful for their patience and encouragement, which have been instrumental in shaping this work.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe authors confirm the availability of full data and material.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEthiopian Health Insurance Service. Annual Performance Report. 2023 (2015 Ethiopian Fiscal Year).\u003c/li\u003e\n\u003cli\u003eWHO), World Health Organization. \u003cem\u003eCommunity Based Health Insurance, Key Facts. \u003c/em\u003e\u003cem\u003ehttps://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-2020. \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eAbebe Sorsa Badacho, Kora Tushune, Yohannes Ejigu, and Tezera Moshago Berheto,. \u003cem\u003eHousehold Satisfaction with a community-based health insurance scheme in Ethiopia. BMC Research Notes: DOI 10.1186/s13104-016-2226-9. \u003c/em\u003e2016.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eDo household perceptions influence enrollment decisions into community-based health insurance schemes in Tanzania? \u003c/em\u003eAlphoncina Kagaigai, Amani Anaeli, Amani Thomas Mori and Sverre Grepperud. Tanzania : s.n., 2021.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eUtilization of the Ghana National Health Insurance Scheme and its association with patient perceptions on healthcare quality. \u003c/em\u003eHAW, NEL JASON L. Ghana : s.n., 2018\u003c/li\u003e\n\u003cli\u003eMebratie A.D. et al. Impact of Ethiopian Pilot Community-Based Health Insurance Scheme on Health-Care Utilization: A Household Panel Data Analysis. The Lancet Global Health, 3(3). 2015\u003c/li\u003e\n\u003cli\u003eDerseh A, Sparrow R, Debebe ZY, Alemu G, Bedilu B, Mekonnen Y. [Online] 2018\u003c/li\u003e\n\u003cli\u003eCommunity‐Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia - Kaso - 2022 - Journal of Environmental and Public Health - Wiley Online Library\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":" \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRenewal Decision of CBHI Members by Perception Status in 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRenewal Decision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePerception Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative Perception\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive Perception\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1650 (40.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2434 (59.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4084\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e136 (75.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (24.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of the bivariate analysis of factors influencing the level of perception of the CBHI program\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePerception Items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePositive Perception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e95% C.I. for EXP(B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e95% C.I for EXP (B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWrit Read Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary TVET\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma \u0026amp; Above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced or Widow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed by others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.611\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent \u0026amp; No job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDuration of CBHI membership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;/= 3years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMembership type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaying Member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" 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char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e 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Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4970275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4970275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study investigates the perceptions of Community-Based Health Insurance (CBHI) holders across various regions and demographic factors in Ethiopia, focusing on their views regarding key aspects of the CBHI program. CBHI initiatives are crucial for enhancing healthcare access and providing financial protection, especially in low- and middle-income countries. In Ethiopia (since 2011), the CBHI program has been part of broader health sector reforms aimed at reducing out-of-pocket (OOP) healthcare expenses and improving service delivery [1].\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis study employs data from a national customer survey and analyzes responses from CBHI members, who rated aspects such as registration, contribution rates, service efficiency, and travel costs on a five-point Likert scale. This national survey employed a correctional study design and a questionnaire as a data collection tool. Descriptive statistics, chi-square tests, and composite variable scoring were used to interpret the data.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003ethe Key findings reveal a strong positive perception of the registration process, with 91% of respondents viewing it favorably and 88% finding the contribution rates fair. These elements are crucial for member retention and the sustainability of the CBHI scheme. However, only 75% of the respondents were satisfied with the convenience of services provided under the CBHI, indicating significant areas for improvement, particularly in terms of the efficiency and quality of healthcare services. The study also highlights substantial regional differences, with Dire Dawa showing the highest positive perceptions and Benishangul Gumuz the lowest. Additionally, factors such as age, employment status, duration of CBHI membership, healthcare usage, residence, and awareness level significantly influenced members' perceptions.\u003c/p\u003e\u003ch2\u003eConclusion and Recommendation:\u003c/h2\u003e \u003cp\u003eThe findings underscore the need to address region-specific challenges and demographic disparities within the CBHI program. While highly positive perceptions of registration and contribution fairness are encouraging, less favorable views of service convenience and regional disparities suggest uneven program implementation. To improve CBHI effectiveness, policymakers should focus on enhancing service convenience, particularly in regions with higher negative perceptions, through better resource allocation, staff training, and infrastructure improvements. Addressing demographic disparities, particularly among rural populations, younger age groups, and lower-income households, is also essential. Future research should explore these disparities further and evaluate the long-term impact of the CBHI on healthcare access and financial protection.\u003c/p\u003e","manuscriptTitle":"Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-24 08:05:40","doi":"10.21203/rs.3.rs-4970275/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e929a74-9aea-4453-8ff9-848633d6d20b","owner":[],"postedDate":"September 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T07:39:02+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-24 08:05:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4970275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4970275","identity":"rs-4970275","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}