|Year : 2019 | Volume
| Issue : 1 | Page : 22-27
Pattern of referral before and after referral intervention among primary health centers in North-Western Nigeria
Sunday Asuke1, Kabir Sabitu2, Muhammed Sani Ibrahim2
1 Department of Community Medicine and Primary Health Care, College of Health Sciences (Jos Campus) Bingham University, Karu, Nassarawa State, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||15-Oct-2019|
Dr. Sunday Asuke
Department of Community Medicine and Primary Health Care, College of Health Sciences (Jos Campus), Bingham University, Karu, Nassarawa State
Source of Support: None, Conflict of Interest: None
Introduction: The revised Nigerian National Health Policy and the WHO Expert Committee on the Role of Hospitals as the First Referral Level both recognize primary health care (PHC) as the entry point in the referral system. This study was carried out to assess the effect of training of PHC workers on referral and instituting referral focal person among PHCs on key referral indicators in Zaria and Giwa local government areas, North-Western Nigeria. Methodology: The study was a quasi-experimental study with pre- and postinterventional components carried out among seventy participants in the intervention and 62 participants in the control groups who were selected through a multistaged sampling technique. Data were collected using a structured self-administered questionnaire containing close-ended questions. Data were analyzed with SPSS software version 20.0. Results: Preintervention, majority of the respondents (74.3%) in the intervention and (67.7%) control groups had not received training on referral process. Postintervention, increase was noted in mean referral rate from 0.18 ± 0.28 to 0.52 ± 0.34, which was statistically significant, and mean counter referral rate from 0 ± 0 to 40.34 ± 45.53 in the study group, but there was no statistically significant change in the control group. Conclusion: Postintervention, significant increases were noticed in two of the practice indicators; referral rate and counter-referral rate in the study group only. The other practice indicators did not record a significant increase.
Keywords: Practice indicators, primary health care, referral, Zaria
|How to cite this article:|
Asuke S, Sabitu K, Ibrahim MS. Pattern of referral before and after referral intervention among primary health centers in North-Western Nigeria. Arch Med Surg 2019;4:22-7
|How to cite this URL:|
Asuke S, Sabitu K, Ibrahim MS. Pattern of referral before and after referral intervention among primary health centers in North-Western Nigeria. Arch Med Surg [serial online] 2019 [cited 2020 Jan 28];4:22-7. Available from: http://www.archms.org/text.asp?2019/4/1/22/269236
| Introduction|| |
Effective referral system is the cornerstone for integration of services at the primary, secondary, and tertiary levels of health care.
Patients that cannot be managed at primary health care (PHC) are expected to be referred to the next level of care. The revised Nigerian National Health Policy and the WHO Expert Committee on the Role of Hospitals as the First Referral Level both recognize PHC as the entry point in the referral system., An effective referral network from the PHC is an important framework for reducing waste, improving access to health care, and reducing inequality, which would contribute to the attainment of the Sustainable Developmental Goal 3 (SDG 3).
A number of factors have been shown to affect referral, such as perceived need of the referral as indicated by the severity of the disease, caregiver and community impression as it relates to the referral facility, and the cost which has to do with time and the resources. Geographical accessibility and trained health-care workers (HCWs) are other important components of effective referral among the various levels of health care.
PHC centers in Nigeria are still associated with a lot of problems including inaccessibility due to poor road network and topography, and they are mostly poorly equipped, ill financed, and inadequately staffed, contributing to poor performance of the referral process., The referral pattern in a lot of countries is such that there is a high bypass phenomenon whereby patients bypass PHCs, leading to shortage of resources at the referral facility and idleness at the PHCs., A study in Tanzania revealed an actual referral rate of 3%, with majority of the patients referring themselves to the referral facility. Another study in Ghana also revealed a referral rate of 3%. Behavior of the HCW is an important contributor of the referral rate. In a study in central Kenya, possible adherence to HCW's advice was identified as a determinant of referral rate.
Another integral part of the referral process is the patient's and caregiver's completion of the referral process because failure to complete the referral is an indication of unmet needs. A study in rural Niger revealed that referral compliance was lower for under-fives due to the associated excess mortality. It also brought to light that compliance for emergency referral was low despite the high referral rate. Another study in Tanzania revealed a high compliance rate, though majority of the patients had a delay of at least 48 h before getting to the facility, while a study conducted in northern Nigeria recorded a compliance rate of 37.8%. In a bid to improve referral, some categories of HCWs have adopted some strategies. In the study in rural Niger, the nurses went all the way to convince reluctant patients directly or through their families and even issued threats.
Referral feedbacks are an important connection between referring and referral facilities. A study in Honduras revealed that HCWs were discouraged for lack of feedback from referral facilities. The same study also suggested that feedbacks served as a means of continuous education for HCWs at referring facilities. The study conducted in Tanzania identified supportive supervision and improved referral feedback as key strategies to improve the health-care delivery system. There is a dearth of information on referral indicators in northern part of Nigeria. This study was carried out to assess the effect of training of PHC workers on referral and instituting referral focal person among PHC centers on key referral indicators in Zaria and Giwa local government areas (LGAs), North-Western Nigeria.
| Methodology|| |
Zaria LGA is one of the 23 LGAs in Kaduna state, and it served as the study LGA, while Giwa LGA which is also one among the 23 LGAs in Kaduna state served as the control LGA. Zaria LGA has a projected population of 493,782 and Giwa LGA 354,661 based on the 2006 census. The major occupation in both LGAs is farming and trading, whereas a few are public servants and students.
Zaria has one general hospital as the referral hospital, 18 PHC centers, 16 health centers, and 25 private clinics. It has 34 PHC health facilities, with a total staff strength of 485. Of these staff, only 208 are directly involved with patient management, 37 of which are record staff. Giwa LGA, on the other hand, has a general hospital as the referral facility, 17 PHC centers, 28 health centers, and 9 private clinics. It has 45 PHC facilities, with a total staff strength of 302, out of which 189 are directly involved with patient management, 25 of which are record staff.
There are no referral focal persons, and there was no system in place for tracking referrals. Services provided by the PHCs include outpatient, child welfare, immunization, antenatal care, postnatal care, family planning, and laboratory services.
The study was a quasi-experimental study with pre- and postinterventional components.
The study population comprised of PHC workers who were directly involved in patient management or record keeping. These were record staff, nurse-midwives, midwives, community health officers, and community health extension workers who had worked in the selected PHC facilities for the past 1 month. Also included were record staff in the general hospital. For a health facility to be included in the study, it must have had at least two medical record staff; have had at least two health workers (HWs); should have offered antenatal care and delivery care; and should have offered child welfare services. Tenure workers of less than a month, pharmacy assistants, laboratory assistants, health attendants, and watchmen were excluded from the study.
A multistage sampling technique was used to select participants. In the first stage (selection of health facilities within an LGA), the inclusion and exclusion criteria stated above were used to select the PHC centers. A total of eight health facilities in the intervention and 11 in the control LGAs met the inclusion criteria, making a total of 19 health facilities. In the second stage (selection of HCWs), it was total population study of HCWs that met the inclusion criteria. Applying the inclusion criteria, 70 participants in the intervention and 62 in the control groups were studied. The study was conducted on all the patients referred.
Data collection involved the use of a structured selfadministered questionnaire structured and coded containing closeended questions, mostly adopted from other works done on referral system.,, The questionnaire had the following three sections (a) sociodemographic characteristics of the HW, (b) knowledge of respondents on referral system, and (c) practice of referral process by respondents. Data were collected pre and post intervention.
An interactive training intervention was carried out for the participants for 3 weeks involving the concept of referral and instituting referral focal persons in the selected PHC centers who were already existing record staff of the facilities. In addition, there was introduction of referral focal persons' directory in the selected PHC centers and the secondary referral facility for feedback. Finally, there was modification of the already-existing referral form and introduction of referral and counter-referral registers in addition to the already-existing outpatient register.
Instituting referral focal persons
This was done at both the referring and the referral center. These focal persons were selected from the already-existing record staff of the facilities. They were trained by the researcher over the same 3-week period using a training module designed and modified by the researcher to fit the study objectives and then given supportive supervision. They were responsible for documentation of all referrals and feedbacks and also facilitated referrals. In addition, there was introduction of referral focal persons' directory to facilitate feedbacks.
Modification of referral forms
A referral form was developed based on the operational training manual and guideline for the development of PHC centers in Nigeria, This normally has a copy of the referral form and a feedback slip. For this study, the form was modified by the researcher to come as a triplicate and provided to the LGA. When a patient is referred, this additional copy was detached and kept in the patient's folder to follow up the referral process, and the other was given to the patient to be taken to the referral center.
Introduction of referral and feedback registers
Normally, these facilities in the study areas are supposed to have these registers at their facilities for documentation, but it is the outpatient register that was available. For this study, two registers, one for referral and the other for feedback, were developed and supplied to the LGA by the researcher. The referral focal persons used these registers for documentation.
Data collected were cleaned and analyzed using IBM SPSS Statistics for Windows, Version 20.0. Released 2011. (Armonk, NY: IBM Corp.). Microsoft Office Excel 2013 was used for the construction of pie chart. Chi-square test was used to test for statistical significance of relationship at P < 0.05. The scores for responses to questions on knowledge were added up, and the percentage scores were computed and classified as follows: poor knowledge is scored below 50%, fair between 50% and 70%, and good above 70%.
Practice of referral was assessed using the following four indicators:
- Utilization rate for referring facility: This is the number of patients or caregivers attended to by the referring facility divided by the target population. This gives an indication of the utilization of the health facility by the target population
- Referral rate: This is the number of patients or caregivers referred from the referring facility divided by the total number of patients or caregivers seen. This tells what proportion of patients seen end up being referred to the referral center
- Referral uptake rate: This is the number of referred patients or caregivers presenting at the referral center divided by the total number of patients or caregivers referred. This indicates partial completion of referral
- Counter-referral rate: This is the number of patients or caregivers reporting from referral center to the referring facility with completed feedback form divided by the number of patients or caregivers referred. This indicates completion of the referral process.
For all the indicators above, the mean and standard deviation per LGA were computed and used for the analysis.
Measurement of changes in indicators
For each LGA, the change in an indicator of referral was measured by comparing its preintervention level with its postintervention level, and the statistical significance of the difference between these levels was tested using t-test at P < 0.05.
Ethical clearance was obtained from the Ethical and Scientific Committee of Ahmadu Bello University Teaching Hospital, Zaria. Permission was also obtained from the LGAs through the respective PHC coordinators and all the officers in-charge of the selected health-care facilities, before the study was conducted. Informed consent was also sought from the participants.
| Results|| |
There was no statistically significant difference in the level of referral training between the intervention and control groups [Table 1]. Comparison of the background characteristics between the intervention and the control LGAs had already been presented in a previous publication. Also, pre intervention, majority of the respondents (74.3%) in the intervention and (67.7%) control groups had not received training on referral process [Table 1]. Pre intervention, practice mean indicators were comparable in both the study and control groups [Table 2]. There was no statistically significant difference in any of the practice indicators.
|Table 1: Preinterventional levels of attendance of referral training among the study and control groups|
Click here to view
|Table 2: Comparison between preinterventional practice indicators in the study and control groups|
Click here to view
Post intervention, there was an increase in mean referral rate from 0.18 ± 0.28 to 0.52 ± 0.34 in the study group [Table 3] but no statistically significant change in the control group [Table 3]. There was also a statistically significant change in mean counter-referral rate from 0 ± 0 to 40.34 ± 45.53 in the study group but no change in the control group. There were no statistically significant changes in other practice indicators in the study and control groups.
|Table 3: Comparison between pre- and postinterventional practice indicators in the study and control groups|
Click here to view
Majority (58%) of the cases referred following the intervention were as a result of pregnancy complications in the study group [Figure 1]. However, no documentation was captured in the control group.
|Figure 1: Causes of referral among patients from the intervention local government area|
Click here to view
| Discussion|| |
Health-care systems are often designed to encourage patients to seek care first at the primary level and then be referred to a higher level of care, if necessary. Provided referral services are accessible, referral staff must be trained to provide quality care; services must be affordable; and essential drugs, supplies, and equipment must be available. With all of these in place, if patients or health caregivers follow the referral pathway, then the health-care cost for the caregivers will be minimized.
Pre intervention, the low health facility utilization rate in both groups was similar to the finding in rural Niger. The low health facility utilization rate obtained in this study could be as a result of the bypass phenomenon, which is a common finding in low-resource settings where PHC centers are bypassed for hospitals.,, Other factors predicting health facility utilization include the cost and perceived quality of medical services.
PHC centers will not work unless there is effective hospital support to deal with the referred patients and to refer patients who do not require hospital attention back to one of the other PHC services. Pre intervention, in both the study and control groups, referral rates were low. This is similar to the finding in Tanzania, Honduras, and Niger, which reported low average referral rate in health centers.,, However, the referral rate recorded in this study is lower than the finding in rural Ethiopia which reported 5% referral rate in health centers.
Pre intervention, the percentage of patients that actually reported to referral centers in both the study and control groups was lower than that in Uganda and Eritrea., Barriers to successful completion of referrals are known to vary from region to region. A study in Ecuador  considered common barriers to completion of the referral process to include demographics, socioeconomic status, family dynamics, caregivers' perceived problems, access, and health system–caretaker interaction. This highlights the need to strengthen the referral system in such PHCs. The Ecuador study found that HW's behavior, provision of a written referral slip, and counseling the caretaker to immediately seek referral care are the most important factors in predicting the completion of referral.
Pre intervention, the percentage of counter-referral rate was found to be zero in both the study and control groups. This is lower than the study conducted in Honduras  which reported a counter-referral rate of 1.4%.
Postintervention, the facility's mean utilization rate in both the study and control groups remained low. This could be because apart from training given to HWs, other factors could be involved that cause patients to utilize a facility. In addition, following the intervention, there was an increase in the mean referral rate, which revealed that the intervention had a positive effect through provision of training, referral forms, and registers, which helped capture more referrals.
Postintervention, the mean referral uptake rate increased. It was not surprising that there was no significant increase in uptake rate in the study group. This is because referral uptake rate is the most complex aspect of a referral process because it is determined by numerous factors including the perceived need of the referral, caretaker or community experience with an impression of the referral facility, and cost. In a study in rural Niger, referral uptake rate was difficult to monitor because patients had different options of hospitals to choose from despite being referred.
Pre intervention, there was no counter-referral rate in both the study and control groups. Post intervention, there was an increase in the mean counter-referral rate from 0 to 40.34 ± 45.53 and no counter-referral rate was recorded in the control group. This change in the study groups was statistically significant. Characteristics of the referred patients revealed that majority of the referrals were as a result of complicated labor.
Possible limitations during the study included “Hawthorne effect.” This could have influenced the HWs' practice of referral monitoring visits by the researcher. Furthermore, during the study, one of the selected PHC centers in the intervention LGA was renovated, and it had to be moved to a temporary site (a community member's house). At this point, they were offering skeletal services and documentation was minimal.
| Conclusion|| |
Prior to intervention, both the study and control groups showed low levels of patients' or caregivers' completion of referral and low or absent levels of some practice indicators. Postintervention, significant increases were noticed in two of the practice indicators, namely referral rate and counter-referral rate in the study group only. The other practice indicators did not record significant increase; this could be as a result of an interplay of other factors that determine utilization rate and referral uptake rate in the completion of referral.
In order to contribute to achieving target 8 of SDG 3, the government has to strengthen the weak referral system through the health departments of each LGA in collaboration with the state PHC development agency to ensure the training and retraining of PHC workers at referral process. It should also ensure that all necessary materials needed for effective functioning of the referral process are always available, for example, referral form and referral registers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Hospital and Health for All. Report of a WHO Expert Committee on the Role of Hospitals as the First Referral Level. Technical Report Series, No. 744. Geneva: World Health Organization; 1987. p. 20-33.
Stigler FL, Macinko J, Pettigrew LM, Kumar R, van Weel C. No universal health coverage without primary health care. Lancet 2016;387:1811.
Kim C, René S, Misun C, Henry DK. Rapid Assessment of Referral Care Systems: A Guide for Program Managers. Published by the Basic Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International Development. Arlington, Virginia: Basic Support for Institutionalizing Child Survival Project; 2003.
Health Reform Foundation of Nigeria. Material Resources for Primary Health Care Infrastructure, Drugs, Equipment and Supplies. Primary Health Care in Nigeria: 30 Years after Alma Ata. Nigeria Health Review; 2007. p. 92-102.
Parakoyi DB, Akande TM, Musa IO. A survey on utilization of comprehensive health centre. Savannah Med J 2001;4:14-6.
Tabibzadeh I, Liisberg E. Response of health systems to urbanization in developing countries. World Health Forum 1997;18:287-93.
Font F, Quinto L, Masanja H, Nathan R, Ascaso C, Menendez C, et al.
Paediatric referrals in rural Tanzania: The Kilombero district study – A case series. BMC Int Health Hum Rights 2002;2:4.
BASICS II and the Ghana Health Service. The Status of Referrals in Three Districts in Ghana: Analysis of Referral Pathways for Children under Five: Atwima, Gomoa, and Yendi Districts. Arlington, VA: BASICS, for USAID; 2003.
Nordberg E, Holmberg S, Kiugu S. Exploring the interface between first and second level of care: Referrals in rural Africa. Trop Med Int Health 1996;1:107-11.
Bossyns P, Abache R, Abdoulaye MS, Miyé H, Depoorter AM, Van Lerberghe W. Monitoring the referral system through benchmarking in rural Niger: An evaluation of the functional relation between health centres and the district hospital. BMC Health Serv Res 2006;6:51.
Musa EO, Ejembi CL. Reason and outcome of pediatric referrals from first-level health facilities in Sabon Gari, Zaria, Northwestern Nigeria. J Community Med Prim Health Care 2004;16:10-5.
Kumiko O, Victor M, Naruo U, Gen O. Study of a patient referral in the republic of Honduras. Health Policy Planning 1998;13:433-45.
Ekwueme OC. Knowledge and practice of patients' referrals among nurses and nurse assistants at the primary health care (PHC) centres in Enugu, Nigeria. Ebonyi Med J 2010;9:119-25.
Federal Ministry of Health, Abuja Nigeria. Operational Training Manual and Guidelines PHC Management Information System. Vol. 3. Federal Ministry of Health, Abuja Nigeria; 2004. p. 20.
James GR, Svetlana N. Development of a Monitoring Framework for Referral within a Network of HIV/AIDS Service Providers: Condensed Final Report based on Four Case Studies; 2009.
Asuke S, Ibrahim MS, Sabitu K, Asuke AU, Igbaver II, Joseph S. A comparison of referrals among primary health-care workers in urban and rural local government areas in North-Western Nigeria. J Med Trop 2016;18:93-7. [Full text]
Mwabu GM. Referral systems and health care seeking behaviour of patients: An economic analysis. World Dev 1989;17:85-92.
Audo MO, Ferguson A, Njoroge PK. Quality of health care and its effects in the utilisation of maternal and child health services in Kenya. East Afr Med J 2005;82:547-53.
Low A, de Coeyere D, Shivute N, Brandt LJ. Patient referral patterns in Namibia: Identification of potential to improve the efficiency of the health care system. Int J Health Plann Manage 2001;16:243-57.
Sauerborn R, Ibrango I, Nougtara A, Borchert M, Hien M, Benzler J, et al.
The economic costs of illness for rural households in Burkina Faso. Trop Med Parasitol 1995;46:54-60.
Bossyns P, Van Lerberghe W. The weakest link: Competence and prestige as constraints to referral by isolated nurses in rural Niger. Hum Resour Health 2004;2:1.
Kloos H. Utilization of selected hospitals, health centres and health stations in central, southern and Western Ethiopia. Soc Sci Med 1990;31:101-14.
Peterson S, Nsungwa-Sabiiti J, Were W, Nsabagasani X, Magumba G, Namboze J, et al
. Coping with Pediatric Referral Ugandan Parents' Experience. Kampala: Uganda Ministry of Health; 2003.
Salgado R, Mehari M, Wendo D, Choi M. The Status of Referral in Eritrea: Analysis of Referral Pathways in Children under Five. Arlington, VA: John Snow, Inc.; 2002.
John Snow, Inc. A Study of Referral Non-compliance in the ARI Strengthening Program, JSI/Nepal, in Collaboration with CDD/ARI Section, MOH, HMG, Nepal. Washington, DC: John Snow, Inc.; 1997.
Manongi RN, Marchant TC, Bygbjerg IC. Improving motivation among primary health care workers in Tanzania: A health worker perspective. Hum Resour Health 2006;4:6.
[Table 1], [Table 2], [Table 3]