The prevalence and incidence of sleep disorder symptoms, correlates, and sex-stratified longitudinal associations with mental and menstrual health outcomes in UK Service Personnel: a prospective surve

Chronic non-communicable diseases (NCDs), including cardiovascular disease, cancer, diabetes, and chronic respiratory conditions, now account for 74% of deaths globally, with 82% of premature NCD deaths occurring in low- and middle-income countries (LMICs) []. Sub-Saharan Africa is experiencing one of the fastest NCD transitions, with chronic disease rising rapidly while many health systems remain organized around episodic rather than long-term care [,]. Nigeria, the region's most populous country and one of its most under-insured health systems, illustrates the financial-protection gap created by this transition. Out-of-pocket payments still account for more than 70% of health spending, federal health allocations have remained close to 4% of public expenditure, and about 30% of households affected by NCDs experience catastrophic health expenditure (CHE) when measured against the WHO 40%-of-non-food-expenditure threshold [,], one of two commonly used CHE metrics in the financial-protection literature. Affordability barriers are often the first point at which this burden becomes visible. Affordability has been conceptualized as the fit between the cost of seeking care and a household's capacity to pay; when that fit fails, care is delayed, modified, or abandoned []. Nigerian evidence suggests that this failure is common. More than two-thirds of diabetes patients in a tertiary setting have reported care as unaffordable []; older adults using Lagos primary care centers identify laboratory and medication costs as major barriers []; and among hypertensive patients in Ekiti, medication adherence varies inversely with the cost of admissions and admission-related medicines []. A West African scoping review similarly identifies high care costs and supply gaps as major barriers to diabetes primary care across the sub-region []. However, this literature has not shown how affordability barriers differ by facility tier, financial exposure, and disease complexity within a single Nigerian chronic-NCD cohort. When cost does not prevent care altogether, households must find ways to absorb it. The McIntyre framework describes a progression from formal and self-directed coping, such as savings, household income, and insurance, through social-network support from relatives, friends, and religious institutions, to distress financing through borrowing, asset sales, and other debt-generating strategies []. Evidence from South Asia shows distress financing as a frequent response to NCD costs, with reported prevalence ranging from 58% in Bangladesh hospitalization studies [] to 72.4% in Indian breast cancer care [], while Tanzanian informal-sector evidence shows heavy reliance on cash, borrowing, and asset sales among populations outside insurance protection []. In sub-Saharan Africa, however, evidence on coping strategies remains limited. A recent scoping review found that NCD coping data are concentrated in a small number of countries and are often measured using broad composite indicators that obscure differences by tier, subgroup, and coping pathway []. In Nigeria, the pattern of distress financing among chronic NCD outpatients remains poorly characterized.