Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study

Abstract

Context and objectiveEthiopia’s primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0–59 months of age and evaluate the healthcare providers’ adherence to referral guidelines.DesignA cross-sectional facility-based survey.SettingThis study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child’s characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions.Outcome measureReferral to the nearest health centre of sick young infants aged 0–59 days and sick children 2–59 months.ResultsThe health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2–59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group.ConclusionFew children with severe illness were referred from health posts to health centres. Improving the health posts’ medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.

Assessing Facilitators and Barriers to Referral of Children Under the Age of Five Years at Ndirande Health Centre in Blantyre, Malawi

“…Our study showed that referral is initiated to avert a negative health outcome that may occur if there is a delay in referring a child for advanced care which is consistent with guidelines for the management of childhood illnesses. 27 Previous research reported that health care workers refer seriously ill children the most 41 and this may result in delayed referral of other children that are not in a serious condition which may deteriorate their health. Health care workers in our study make efforts to provide pre-referral treatment within the facility before referring the patient for further management which is consistent with previous studies where health workers administered artesunate and paracetamol before referring a patient.…”

“…38,39 Our findings that the unavailability of resources triggers a referral is consistent with earlier findings in Malawi and other settings that showed that shortage of health workers, lack of essential equipment, and medicine stock-outs influences referrals. 17,28,41 This may mean that some of the cases being referred could have been managed at the primary facility if resources were available while the act of referral, in this case, burdens the next level of care unnecessarily. 40 The lack of resources like diagnostic equipment, drugs, health care workers, in health services is a major problem across several LMICs.…”

A systematic scoping review of medicine availability and affordability in Africa

“…Lack of access to medicines due to their poor availability or affordability negatively affects health service quality, equity and health outcomes in Africa in a variety of ways. Medicine affordability or availability in Africa is associated with medication adherence [ 1 – 3 ], prescribing decisions [ 4 – 6 ], patient choice of health facility [ 7 – 9 ], patient satisfaction [ 10 – 12 ], care seeking behavior [ 13 , 14 ], referral patterns [ 15 ], compliance with treatment guidelines [ 16 ], and health outcomes [ 1 , 17 , 18 ]. Unaffordability of medicines in the formal sector has also been shown to drive patients to informal markets where medicine quality may be poor [ 19 ].…”

A systematic scoping review of medicine availability and affordability in Africa

“…Lack of access to medicines due to poor availability or affordability negatively affects health service quality and equity in Africa in a variety of ways. Medicine affordability or availability in Africa has been associated with medication adherence, 1,2,3 prescribing decisions, 4,5,6 patient choice of health facility, 7,8,9 patient satisfaction, 10,11,12 care seeking behavior, 13,14 referral patterns, 15 compliance with treatment guidelines, 16 and health outcomes. 17,18,19 Unaffordability of medicines in the formal sector has also been shown to drive patients to informal markets where medicine quality may be poor.…”