Annals of African Medicine
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Year : 2010  |  Volume : 9  |  Issue : 3  |  Page : 176-180 Table of Contents     

Awareness and perception toward referral in health care: A study of adult residents in Ilorin, Nigeria

1 Department of Community Medicine, Ladoke Akintola University of Technology, Osogbo, Nigeria
2 Department of Epidemiology and Community Health, University of Ilorin, Ilorin, Nigeria

Date of Web Publication11-Aug-2010

Correspondence Address:
O L Abodunrin
Department of Community Medicine, Ladoke Akintola University of Technology, Osogbo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1596-3519.68359

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Background and Objective: The Nigeria Health System operates three levels of health care, which correspond to the tiers of government and interacts through a referral system. The national health policy recommends the Primary Health Care (PHC) as the entry point to health care system. However, these facilities are poorly managed leading to underutilization. Therefore, people usually attend any facility that will meet their needs, not considering the appropriateness of the level of care. This study is to determine the awareness and perception of adult residents in Ilorin toward referral in health care.
Methods: A cross-sectional descriptive survey was conducted among 366 adult residents in Ilorin, selected by multi-stage sampling technique. Data were obtained using a semi-structured questionnaire, appropriately scored and analyzed with Epi-Info 2005 computer software.
Results: Only 22 (6.0%) respondents knew that PHC is supposed to be the fi rst point of call when ill and 25 (6.8%) were aware that referral hospitals have the right to reject patients without referral. More than two third, 256 (69.9%) of the respondents felt it will be unreasonable for any hospital to reject patients on the basis of not being referred.
The level of education was signifi cantly associated with the knowledge and perception of referral in the health care.
Conclusion: There is low awareness and poor perception of referral protocol in the health care system among the people of Ilorin. The higher the level of education, the more knowledge the respondents have about referral in the health system and the more likely they have correct perception of referral in health care. The Nigeria health care system policy on referral and appropriate hospital utilization could be more effective if public awareness is created about it via the media while making effort to improve the credibility of the PHC.

   Abstract in French 

Arrière-plan et objectif: Le système de santé du Nigeria exploite trois niveaux de soins de santé, qui correspondent à la les niveaux de gouvernement et interagit grâce à un système de renvoi. La politique nationale de santé recommande le principal. Soins de santé (HCP) comme entrée point au système de soins de santé. Toutefois, ces installations sont mal gérées menant à la sous-utilisation. Par conséquent, personnes assistent généralement à toute installation qui répondra à leurs besoins, ne pas considérer la pertinence du niveau de soins. Cette étude vise à déterminer la sensibilisation et la perception des adultes résidents dans Ilorin vers le renvoi dans les soins de santé.
Méthodes: Une enquête descriptive transversale a été réalisée entre résidents adultes 366 Ilorin, sélectionné par échantillonnage multiétape technique. Données ont été obtenues à l'aide d'un questionnaire semi-structuré, convenablement notation et analysées avec Epi-info 2005 logiciels.
Résultats: Les répondants seulement 22 (6,0 %) savaient que PHC est censé pour être le point de première fi d'appel lorsqu'il est malade et 25 (6,8 %) savaient que les hôpitaux de recours ont le droit de rejeter les patients sans renvoi. 256 Tiers, plus de deux (% 69.9) le feutre de répondants il sera déraisonnable pour n'importe quel hôpital de rejeter les patients sur la base des n'étant ne pas visés. Le niveau d'éducation était important considérablement associé à la connaissance et la perception de renvoi dans les soins de santé.
Conclusion: Il est faible sensibilisation et une mauvaise perception de protocole de renvoi dans le système de soins de santé parmi les gens de Ilorin. Plus le niveau d'éducation, de la connaissance plus les répondants ont sur renvoi dans le système de santé et les plus susceptibles d'avoir une perception correcte de renvoi dans les soins de santé. Les soins de santé du Nigeria système politique sur le renvoi et l'utilisation appropriée d'hôpital pourrait être plus efficace si la sensibilisation du public est créée. sujet via les médias tout en faisant des efforts visant à améliorer la crédibilité de la HCP.
Mots-clés: Prise de conscience, de soins de santé, de perception, de soins de santé primaires, de renvoi

Keywords: Awareness, health care, perception, primary health care, referral

How to cite this article:
Abodunrin O L, Akande T M, Osagbemi G K. Awareness and perception toward referral in health care: A study of adult residents in Ilorin, Nigeria. Ann Afr Med 2010;9:176-80

How to cite this URL:
Abodunrin O L, Akande T M, Osagbemi G K. Awareness and perception toward referral in health care: A study of adult residents in Ilorin, Nigeria. Ann Afr Med [serial online] 2010 [cited 2023 Sep 25];9:176-80. Available from:

   Introduction Top

The Nigeria Health System operates three levels of health care, namely, the primary, secondary and tertiary levels, which interact through a referral system. [1],[2] The Primary Health Care (PHC) is the entry point to health care system and ideally should be able to provide majority of the essential and basic health care services. The secondary level hospitals are to provide general out- and in-patient services accepting referrals from urban and rural PHC, while tertiary hospitals are to provide specialized services to referrals from secondary hospitals. The national health policy is based on the principle of equity and social justice and the PHC has been recommended as the tool to achieve this. By this, everyone, irrespective of geographical location and socioeconomic status, is expected to have access to quality health care service. 2 Referral is a continuum of care in which case a health care worker assesses that his client may benefit from accessing additional or expert services elsewhere. [3],[4] Ordinarily, referral centers should only deal with referred cases except in emergencies. [3]

However, the Nigeria health system is faced with the challenge of Inverse Care Law in which case people who need health care the most have the least access to it mainly as a result of poor administration and management. [5] Firstly, the PHC facilities are still inadequate with about 30% not within 5 km from any health facility, and even when they are available, they are inaccessible due to poor road network and topography (streams, rivers, hills), [6],[7] In addition, they are poorly equipped, ill financed and inadequately staffed, [6] leading to poor performance and underutilization. The underutilization of the PHC has overburdened the higher levels of care and sometimes these higher levels find it difficult to compulsorily demand for referral before attending to patients, which should have been the ideal situation. [7],[8]

In Nigeria, referral system can be said to be at best non-operational and there is just no continuity of care [9] and this contributes especially to increased maternal and child morbidities and mortalities. There is no proper link between the PHC and the secondary health facilities and in turn with the tertiary. [9] Most major hospitals in sub-Saharan Africa, Nigeria inclusive, provide primary and preventive services, making them overlabored. [8] This is worse in the cities because "big" hospitals are there and members of the communities sometimes may not know the functional difference in the various levels of health care, whether one should be first contact or later visit. [10] If they do not have the correct knowledge, their utilization of these services will not be appropriate apart from other factors.

Determinants of choice of health facilities for care include personnel, proximity, laboratories, equipment, drugs, etc. [7] Therefore, people attend any facility that will meet their needs, not considering the policy guidelines or appropriateness of the level of care. For example in one study, it was discovered that 60% of users of a tertiary hospital in Zimbabwe [11] was for Malaria fever and only 14% of these Malaria cases had severe malaria and were appropriate for this level of care. Furthermore, there is usually no restriction of access to members of the communities seeking health care in many tertiary facilities without being referred from the lower levels of care. A study in Ilorin, Nigeria, by Akande [8] showed that out of 1175 new patients at consultant clinics, only 7.1% were referred. This resulted in overcrowding of the tertiary health facilities, with problems that can be managed at the lower levels. Not only the health care providers need to have adequate knowledge of the referral procedure of the health care system, but also the members of the community need to have appropriate awareness for its success. Studies on community's knowledge of referral in health care are rare. This study is therefore aimed to determine the awareness and perception of adult residents in Ilorin toward the policy on appropriate utilization of levels of health facilities through referral system.

   Materials and Methods Top

The study was carried out in Ilorin metropolis, a city in Kwara state which is in the North-Central zone of Nigeria. It is located between longitude 2 0 45` and 6 0 4`E and latitude 11 0 2 ` and 11 0 45`N. It is situated about 302 kilometers north of Lagos, 602 kilometers south of Kaduna and 475 kilometers south of Abuja the federal capital. There are several health facilities within the city: one teaching hospital, two specialist hospitals, many secondary and primary health facilities including private hospitals. Most of these are within the urban area of the city.

This study was community-based with study population consisting of adults selected from both the inner core (low socio-economic status) and the outer core (high socio-economic status) of the city. All the health professionals were excluded in the study. The study design was a descriptive cross-sectional survey. Through a multi-stage sampling technique, respondents were drawn from the three local governments that are in the metropolis. Selections were from both the inner and outer cores. For the outer core; 6 streets were selected through balloting while 4 were selected for the outer core; 15 houses were then selected through systematic sampling, every fifth house, in each of the streets. A maximum of 3 adults chosen by balloting were interviewed in the houses selected where there are more than 3 adults in a house but where there were less than 3, all the adults were interviewed. The data collecting instruments was a semi-structured questionnaire. A total of 400 questionnaires were administered (both self-administered and interviewer-administered, as appropriate). The data were validated and analyzed with Epi Info 2005 computer software package. Univariate and bivariate analysis (chi square statistical test) were done and presented in form of tables. Statistical level of significance was set at P < 0.05.

For knowledge score: out of the 9 knowledge questions asked, each correct response was awarded 1 mark. Good, fair and poor knowledge were respectively a score of 7-9, 4-6 and 0-3. For perception: 'agree' response was scored 2, 'can't say' was scored 1 while 'do not agree was scored 0; 'fully in support' was scored 3, 'somehow in support' was scored 2, 'indifferent' was scored 1 and 'not in support' was scored 0. Correct reason supplied scored 1 each. A total score of 6-10 was considered "Correct Perception" while 0-5 was considered as "Incorrect Perception"

   Results Top

All the 400 questionnaires that were administered were returned but 366 were correctly filled and suitable for statistical analysis, giving a response rate of 91.5%. The mean age of the respondents was 33.62 ± 4.21 years while the male:female ratio was 0.89:1. Two hundred and sixteen (59.0%) respondents were from the inner core area of the city, whereas 150 (41%) were from the outer core part of the city. Other characteristics are as shown in [Table 1].
Table 1 : Sociodemographic characteristics of the respondents (n = 366)

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Only 22 (6.0%) respondents knew that PHC is supposed to be the first point of call when ill, with their main sources of information being health workers in hospitals 14 (63.6%), friends and family 18 (81.8%). As much as 58 (29.5%) of the respondents knew that the "big" hospitals are meant for severe/special cases while only 25 (6.8%) were aware that referral hospitals have the right to reject patients without referral letters, i.e., those who bypassed the lower health centers. Respondents' gave various perceived reasons for patients' referral in the health care system [Table 2]. The most common reason given was "difficult cases beyond the ability of the referring hospital or doctor" 321 (87.7%), followed by lack of appropriate equipment in the health facility (59.0%). Other reasons given were "for additional management" and incompetence of the health worker at the referring health facility. Yet, some respondents thought that health workers refer patients or pushed them out of their health facilities when the illness has no solution.
Table 2 : Respondents' knowledge of referral system in health care

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From [Table 3], it is seen that only 8 (2.2%) of the respondents felt that PHC as the first point of call should be made compulsory, their only reason being that the laid down regulation and due process must be followed. Among those that did not agree, most of them said that people should be allowed to make their own free choices. About two third [256 (9.9%)] of the respondents felt it would be unreasonable for the teaching hospital or any hospital to reject patients on the basis of not being referred or because the illnesses are minor. Others were of the opinion that such act will be unethical, unlawful and will constitute wickedness to humanity. Of all the respondents, only 23 claimed they had been refused attention in any hospital only on the basis of not been referred.
Table 3 : Respondents' perception toward referral system in health care

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Both respondents' knowledge and perception were associated their level of education with P < 0.01 [Table 4] but not with their area of abode [Table 5]. The higher the level of education, the more knowledge the respondents have about referral in the health system and the more likely they have correct perception of referral in health care. Only about 26% of those with tertiary education had poor knowledge of referral as compared with at least 70% in those with primary, secondary and those without any formal education
Table 4 : Distribution of knowledge and perception of referral by educational status of the respondents

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Table 5 : Distribution of knowledge and perception of referral by area of city where respondents reside

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   Discussion Top

The respondents generally had poor knowledge of referral in the health care system as only about 35.2% of them had average and above average knowledge. There was very poor understanding of the use of PHC as first point of call for health care (6.0%); the respondents did not know the difference between the levels of health care facilities. This finding is supported by that in Zimbabwe [10] that people did not know the functional difference between a hospital, a clinic or basic health centre; they only knew the physical difference. However, the knowledge in this study was found to be associated with the educational level (P < 0.05) unlike the Zimbabwean study; those with tertiary educational level had a better knowledge with about three-quarter of them having a fair knowledge of referral, unlike those with lower level of education. The knowledge was not found to be associated with area of residence as would be expected since most people in the inner core area were of low socioeconomic status and low level of education.

Akande [8] noted in his study in Ilorin that to make clients utilize primary and secondary health facilities, necessary steps need to be put in place and create disincentives for patients bypassing these levels and this was also supported by other studies. [3],[12] Referral policy, which is an essential part of any nation's health system, is facing a lot of problems especially in developing countries leading to overcrowding in the hospitals. [12] Referral hospitals therefore must enforce protocols which its doctors must be aware of.

However, only 2.2% felt that referral from a lower level hospital should be made compulsory; they felt people should be allowed to make free choices. This confirms the fact that people do not know the importance of appropriate use of health facilities. [10] Before the enforcement of such referral protocol, however, the lower health facilities ought to be furnished both with human and material resources so that their morale can be boosted and people can have confidence in them. [7],[8] So also in this study, some of the reasons supplied by the respondents who did not support making referral letter a prerequisite in hospitals were that the peripheral health facilities were inadequate, poorly equipped and poorly staffed. These are some of the reasons why the choice of point of entry into the health care delivery system is not always correct.

In conclusion, this study has shown that there is low awareness, poor knowledge and wrong perception of the members of the Ilorin community about the referral protocol in health care. This awareness and perception are associated with level of education but not with area of the city where the respondents live.

The Nigeria health care system policy on referral and appropriate hospital utilization will be more effective if public awareness is created about it via the media while making effort to equip the peripheral health facilities with drugs, equipment and personnel to improve their credibility. Further studies on different health facilities' procedures and standing orders concerning referral should be investigated.

   References Top

1.Health Reform Foundation of Nigeria. History of the Nigerian Health Sector. Nigeria Health Review 2006. Herfon 2006. p. 1-13.  Back to cited text no. 1      
2.FMOH. Revised National Health Policy. 2004. p. 5-17.  Back to cited text no. 2      
3.Hensher M, Price M, Adomakoh S. Referral hospitals. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, editors. Disease control priorities in developing countries. 2 nd ed. New York: Oxford University Press; 2006. p. 1229-44.  Back to cited text no. 3      
4.Wole A. Referral System. In: Essentials of community health, primary health care and health management. Benin City, Nigeria: Medisuccess Publication; 2000. p. 423-8.   Back to cited text no. 4      
5.Ogunbameru OA. Formulation and implementation of strategic management in health care organizations: An industrial sociologist's perspective. In: Irinoye editors. Optimal Management of Health Care Organizations, Ibadan, Nigeria: Spectrum Books Limited; 2004. p. 66-86.  Back to cited text no. 5      
6.Health Reform Foundation of Nigeria. Material resources for primary health care - infrastructure, drugs, equipment and supplies. In primary health care in Nigeria: 30 years after Alma Ata. Nigeria Health Review 2007. Herfon; 2008. p. 92-102.  Back to cited text no. 6      
7.Parakoyi DB, Akande TM, Musa IO. A survey on utilization of comprehensive health centre. Savannah Med J 2001;4:14-6.   Back to cited text no. 7      
8.Akande TM. Referral system in Nigeria: Study of a tertiary health facility. Ann Afr Med 2004;3:130-3.  Back to cited text no. 8      
9.Health Reform Foundation of Nigeria. Child survival in Nigeria. Nigeria health review 2006. Herfon; 2006. p. 45-75.  Back to cited text no. 9      
10.Hongoro C, Musonza TG, Macq J, Anozie A. A qualitative assessment of the referral system at district level in Zimbabwe: Implications on efficiency and effective delivery of health services. Cent Afr J Med 1998;44:93-7.  Back to cited text no. 10  [PUBMED]    
11.Sanders D, Kravitz J, Lewin S, Mckee M. Zimbabwe's hospital referral system: Does it Work? Health Policy Plan 1998;13:359-70.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.WHO/FHE/MSM. Developing and maintaining a functioning referral system. Care of mother and baby at the health centre: A practical guide. WHO/FHE/MSM/94.2. Revision 2. 1993. p. 38-9.  Back to cited text no. 12      


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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