Understanding healthcare self-referral in Nigeria from the service users’ perspective: a qualitative study of Niger state

Abstract

Background The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60–90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users’ decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users. Methods Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis. Results Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen’s model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users’ expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms. Conclusions The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.

Geographical accessibility in assessing bypassing behaviour for inpatient neonatal care, Bungoma County-Kenya

“…The desire of the care seekers to attain quality care from higher tier facilities despite incurring additional transportation cost and longer travel time, is an indication of what they can sacrifice to access quality care. On the other hand, care seekers bypass their nearest sub-county facilities which are mostly faced with inefficient healthcare system [66]. However, the economically challenged population residing far away from the county level facilities may have to contend with the services offered at the local facilities.…”

Assessment of Bypass of the Nearest Primary Health Care Facility Among Women in Ghana

“…10 Several studies have described substantial variation in individual behavior across different health systems, particularly with regard to childbirth facilities. [4][5][6]11,14,17,[20][21][22][23][24][25][26][27][28][29][30][31][32][33] There is limited evidence characterizing the extent of primary health care bypass in Ghana and West Africa in general. A better understanding of these bypass behaviors may provide insights into local primary health care improvement efforts for policy makers and facility managers.…”

A qualitative study of health care providers’ perceptions and experiences of patients bypassing primary healthcare facilities: a focus from Nigeria

“…These findings echoed the views of the patients from a previous study, who feared they could be given a wrong diagnosis by the healthcare providers within the PHC facilities. 40 The understanding among the patients that the majority of healthcare providers at the primary level of care were either CHWs or nurses further amplified this concern, thus they voiced their preference to be attended to by doctors who are mainly only available at the higher levels of care. 40 A similar finding was reported in the UK, whereby some patients felt the doctors at the emergency department had better knowledge than their general practitioners, which resulted in seeking care at the referral facility.…”

“…40 The understanding among the patients that the majority of healthcare providers at the primary level of care were either CHWs or nurses further amplified this concern, thus they voiced their preference to be attended to by doctors who are mainly only available at the higher levels of care. 40 A similar finding was reported in the UK, whereby some patients felt the doctors at the emergency department had better knowledge than their general practitioners, which resulted in seeking care at the referral facility. 41 Likewise, it's been found that the availability of staff alone does not ensure the delivery of quality care, as healthcare providers can lack the ability to make accurate diagnoses or to appropriately manage patients.…”