Self-referral patterns among federal civil servants in oyo state, South-Western Nigeria

Introduction Primary health care is widely accepted as the first point of care; yet, individuals requiring healthcare engage in self-referrals to higher levels of care thereby by-passing primary care. Little is known of the extent to which self-referrals are carried out when care is needed. This study thus sought to determine the prevalence of self-referral, its patterns and factors influencing self-referrals amongst federal civil servants in Southwestern Nigeria. Methods A cross-sectional study was carried out among 300 federal civil servants who were interviewed using validated and pre-tested interviewer-administered semi structured questionnaires. Data was analyzed using univariate and Chi-square test at level of significance set at P <0.05. Results Mean age of the respondents was 39.96 ± 9.1 years with majority being married (80.7%); 90.7% completed tertiary education (and 76.7 % were middle grade (7-12) level officers. Most (60.0%) of the respondents had ever engaged in self-referral. Malaria was the commonest health problem (39.7%) for self-referral to secondary or tertiary facilities. Desire for quality service (35.7%) and competent staff (35.2%) were the commonest reasons for self-referral to a higher level of health care. More female respondents (76.0%) compared to male respondents (64.0%) significantly engaged in self-referral (p = 0.02, X2 = 5.14). Respondents having good knowledge of referral practices engaged less in self-referral compared to those with poor knowledge. (p = 0.02, X2 = 5.43). Conclusion Having good knowledge of referral practices and being male are positively associated with referral practices. Creating awareness and improving knowledge on referral practices with special emphasis on women population are desirable strategies for encouraging the use of primary health care as first of point of contact with health systems.


Introduction
Prior to independence, millions of people on the geographic or social periphery of African countries received either marginal health care or none at all [1]. Colonial health systems channelled resources to urban dwellers and white settlers at the expense of the predominantly black rural populations who had the greatest need [1]. Many years after independence, Nigeria instituted Primary Health Care (PHC) systems, and developed a pyramidal referral model to support the primary health care level. Clinics and health centres were intended to provide local services for uncomplicated cases, referring patients with more serious conditions to state and teaching hospitals [2]. The Primary Health Care is designed to provide general health services for preventive, curative, promotive and rehabilitative purposes to the population; serving as the entry point of the health care system, while the secondary and tertiary health care renders specialized and highly specialized services respectively to patients that are referred from the primary health care facilities [3]. The development of effective patient referral systems is germane to effective management, prognosis and outcomes of ailments in the hospital setting. "Referral is a process by which a health worker transfers the responsibility of care temporarily or permanently to another health professional or social worker or to the community" [4]. Referral has also been defined as a process in which a health worker at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the assistance of a better or differently resourced facility at the same or higher level to assist in, or take over the management of, the client's case [5]. Referral systems have been considered to be an important component of health systems in developing countries since the emergence of primary healthcare [6]. In practice, referrals are not only between lower and higher-level facilities (considered to be an integral part of allopathic health systems) [6], but also between primary facilities as well as within hospitals which can be vertical, horizontal or diagonal [7]. The referral system thus ensures a continuum of care as patients are required to seek health services from higher tiers of care in the referral system should there be need to do so [8].
Furthermore, it ensures that patients are dealt with in the right place with effective treatment provided at the affordable cost [9].
Advantages of an effective referral system in literature have been also documented to contribute to high standards of care by limiting over-medicalization, permitting an efficient division of tasks between generalists and specialists, freeing specialists to develop their special skills, and by reducing medical cost [10]. Literature has extensively documented the referral of patients within hospital levels both in Nigeria [4] and abroad [11]. Irrespective of the reasons that range from cheaper hospital out-patient services to improved quality [11], self-referral has generated economic concerns and is a practice that should be discouraged if its cons outweighs its pros [12,13]. A recent study conducted in Ilorin found out that only 7.1% were referred from primary health centres to the hospital while 91.9% reported directly without referral [14]. The importance of referral systems has been documented in several studies; however there is a dearth of literature on self-referrals particularly in sub-Saharan Africa notable for self-referrals. This study sought to add to existing body of knowledge by examining patterns of self-referral practices among civil servants. This especially becomes more important in a setting such as Nigeria, a low and middle income country (LMIC), where the health system is not as optimal as that of developed countries. Findings from this study will help to inform health policy decisions geared at strengthening of the health system which comes with improvement on the referral linkage.

Methods
This descriptive cross-sectional study was conducted between October and November, 2014 at the Federal Secretariat Complex, Ikolaba, and Ibadan, Nigeria. Ibadan is the ancient capital city of Oyo State, located in the south-west of Nigeria. Ibadan city is divided into eleven local government areas, 5 in the metropolis and 6 in the peri-urban area [15]. Ibadan is a centre of trade and farming, renowned for its production of cocoa, palm oil, yams, out of these, 300 respondents consented to participate (Response Rate = 84.7%). Two repeat visits were conducted to enrol those who were absent from the secretariat during the initial data collection. Data was collected with the aid of a pre-tested and validated interviewer-administered semi-structured questionnaire.
The questionnaire was pre-tested among 30 civil servants in the Local Government Civil Service Commission at Ibadan North-East.
The pre-tested questionnaire was analysed and necessary modifications effected. Three research assistants with completed secondary school education were trained on data collection.
Knowledge of the referral system was scored based on response to 5 questions. Zero was scored for "not supported", 1 for "indifference", and 2 for "support". A score range of 0-5 was considered poor knowledge while 6-10 was considered good knowledge. Perception of the effectiveness of the referral system was measured and scored using 21 questions on a three point Likert scale (agree, not sure, disagree). Scores of 45 and below were considered as poor perception while above 45 was considered as good perception. The data were coded, checked, and processed with version 20 of the Statistical Package for the Social Sciences.
Descriptive statistics such as means, standard deviations (SD), frequencies, and proportions were used to summarize variables.
Chi-square tests were used to identify associations between categorical variables at 5% level of significance. The University of

Ibadan/University College Hospital (UI/UCH) Ethics Review
Committee approved the study protocol. Verbal informed consent was obtained from the respondents. The privacy and confidentiality of respondents' data were assured.
Malaria was the commonest health problem (39.7%) for which respondents engaged in self-referrals to higher level of health care.
Other common health problems reported as reasons for self-referral included upper-respiratory tract infection (URTI) (12.7%), medical and follow-up checks (11.3%), eye problems (5.0%), birth deliveries (4.0%) and dental procedure (3.7%). Less common health reasons for self-referral include gynecological problems   [18,19]. The differences in rural and urban residence of respondents in these studies might have been partly responsible.
This proportion is also consistent with findings from a similar study  [20]. This lack of understanding is also amplified by findings from a study in Zimbabwe, where a study population did not know the functional differences between a hospital, a clinic and a basic health centre; instead they could only identify the physical differences [17]. From the foregoing, some authors had stressed that the importance of having adequate knowledge on contents and principles guiding management of specific health services and their roles on the referral system cannot be over-emphasised and therefore, should be taken as a complementary when issues of referral are being considered [21,22]. The desire to obtain care from competent staff as a reason for self-referral in this study is corroborated by findings from literature [23]. Nevertheless, the trend and desire had flouted well-established principles guiding access to care in the study setting [24].
In a study conducted at the University College Hospital, Ibadan Nigeria among medical consultants, 84.1% had good knowledge of the referral system [25]. This high level of knowledge is logical since the respondents were medical consultants whose referral of patients was a crucial part of their daily job description and responsibility.
The implication of the above findings is that poor knowledge of referral system will invariably result in misuse or abuse of the health system where health problems that can easily be managed at a lower level of health care are presented at a higher level. A two-way referral system is advocated from the lowest level of health care to the highest, except in emergency situations when patients can be referred to any of the facilities for immediate treatment [26]. This is hardly the case in many developing countries. The practice of bypassing primary health care clinics seems to be driven by a number of factors ranging from the patients' perception of superior quality of care to resource availability in the hospitals; or in other instances, it is simply a case of proximity of a secondary/tertiary hospital to household residences [8]. These assertions were corroborated by our findings as perceived quality of services, qualification of medical staff, reputation and the location of the hospital were given as the main reasons for engaging in self-referral or deciding on the health facility to seek for treatment. Evidence supporting suboptimal quality of services at primary health care facilities abound in the literature [27,28]. In a study conducted in Tanzania, 44.0% of the women seeking care had by-passed their nearest health facility while 59.8% who lived in a village with a functioning health facility had delivered at home [29]. In the study, the women reported that quality of care (e.g. best provider, availability of drugs) and a greater trust in health workers at the health facility were the main reasons for selecting the facility. Findings of a household survey in Lushoto district in Tanzania showed that patients by-passed their lower level of health care to seek hospital treatment because of poor quality of services and poor availability of drugs [30]. In a similar study in Kenya, respondents considered location of the hospital, good reputation of the hospital, quality of care offered at the hospital, friendly staff and aesthetics of the premises as institutional factors for self-referral [31].
Regulated conditions guiding health insured participants might be a good reason why self-referral was not as high as documented in other studies considering that all the participants in this study were civil servants and a considerable number of them were insured by the current National Health Insurance Scheme (NHIS). In this scheme, enrollee referral can only be approved by an accredited and registered health care provider thus discouraging the practice of self-referrals. This process could be responsible for limiting the rate of self-referral among this group of respondents. Liu et al. (2008) reported that among by-passers of primary care, 5.0% cited health insurance as the reason for seeking care by themselves outside their local community [32]. Some reasons provided for self-referrals included little confidence in the care they would receive at the lower hospitals and lack of well-designed referral system with defined Page number not for citation purposes 5 procedures, management support. A potential bias in this study was recall bias which is a usual occurrence with self-reported prevalence surveys. Recall bias was reduced by limiting enquiries on healthseeking behaviour to the last three months. This cut-off has been used widely by researchers in several countries [33,34]. Another limitation is that the cross-sectional design of this study does not allow inferences to be drawn from its results. Furthermore, the fact that our study only sampled federal civil servants at the federal secretariat greatly limits its generalizability to other populations.
Nevertheless, the study provided additional insight into the dynamics and preferences of federal civil servants with regards to access and health seeking behaviours that may be used to project for other federal workers in the country.

Conclusion
A strengthened health care system translates to access to healthcare services for a country's citizens. Appropriate referral between health facilities is one of the indicators of a strengthened health system. To achieve effective functioning of referral systems, health personnel must be competent and available and the citizens must know the importance of the referral system to avoid potential abuse. This study has shown that civil servants practised self- What is known about this topic  A good proportion of patients continue to by-pass primary level health care everyday;  More female patients were engaged in self-referrals however not certain to what extent.

What this study adds
 The study provides information on common ailments that encouraged self-referrals among federal civil servants in southwestern Nigeria;  The study establishes a significant association between gender and self-referrals among the participants (being female was associated with increased levels of selfreferrals);  The study also showed that knowledge has a significant role to play in curbing self-referrals amongst populace (In this study, good knowledge of the referral system was associated with lesser amounts of self-referrals).