Table of Contents  
Year : 2016  |  Volume : 18  |  Issue : 2  |  Page : 93-97

A comparison of referrals among primary health-care workers in urban and rural local government areas in North-Western Nigeria

1 Department of Community Medicine, College of Health Sciences, Bingham University, Karu, Nasarawa State, Asokoro, Abuja, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Kaduna State, Asokoro, Abuja, Nigeria
3 Department of Microbiology, Ahmadu Bello University, Zaria, Kaduna State, Asokoro, Abuja, Nigeria
4 African Field Epidemiology Network, Asokoro, Abuja, Nigeria

Date of Web Publication13-Oct-2016

Correspondence Address:
Sunday Asuke
Department of Community Medicine, College of Health Sciences, Bingham University, Karu, Nasarawa State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2276-7096.192233

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Introduction: In Nigeria, the three tiers of health-care service are linked through the referral system and primary health care (PHCs) are an entry point into this health-care service. Effectiveness of referral system is a strong determinant of the strength of health-care service delivery. This study was conducted to assess and compare knowledge and practice of referral among PHC workers in urban and rural health facilities in two local government areas (LGAs) in Kaduna State.
Methodology: The study was comparative cross-sectional. It enrolled all eligible PHC workers in the study areas; seventy in urban and 69 in rural LGAs. Data were collected using a structured interviewer-administered questionnaire containing close-ended questions.
Results: Majority of the health workers in both LGAs were in the age range 25-34 years. Only 16 (22.9%) of those in urban and 13 (21.0%) in rural PHCs had good knowledge of referral (P = 0.594). In addition, only 9 (12.9%) in urban and 7 (11.3%) in rural PHCs had good practice of referral (P = 0.595).
Conclusion: Knowledge and practice of referral were poor in both urban and rural PHCs. There is an urgent need for training on referral and other forms of intervention such as instituting a referral focal person to improve practice of referral among the health workers in both rural and urban PHCs.

Keywords: Nigeria, primary health care, referral, rural, urban

How to cite this article:
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

How to cite this URL:
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 [serial online] 2016 [cited 2023 Feb 1];18:93-7. Available from:

  Introduction Top

Based on the 2006 Census, [1] Nigeria has a projected population of 185.13 million and majority of this population resides in the rural areas. Nigeria is one of the many low- and middle-income countries (LMIC) in Africa experiencing shortage of human resources for health (HRH). The World Health Organization (WHO) report on HRH indicates that there is an alarming deficiency of HRH particularly in Sub-Saharan Africa with an estimated deficiency of 817,992 health workers. [2] The report also states that there is inequity in the distribution of health workers "across regions and within countries" with about 80% of doctors and 60% of nurses found in urban areas and a more concentration in the private sector. This is similar to the Nigerian context where primary health care (PHC) records a deficiency of 50% of HRH and an unbalanced distribution of HRH between zones and among urban and rural areas. [3] This is further worsened by the fact that Nigeria like other African countries produces about 10% of the HRH it needs and majority of these workforces relocate abroad to search for better jobs. [2] The deficiency of number and quality of HRH is most marked in Northern Nigeria. [3] HRH deficiency, if not urgently talked, will slow down the actualization of a key Sustainable Developmental Goal. This will hence affect the health-care delivery system negatively. It was also observed that PHC facilities in Nigeria are still inadequate with about 20% of households not within 5 km from any health facility in the urban areas and 38% in the rural areas, and even when they are available, they are inaccessible due to poor road network and topography. [3] Some interventions could be put in place to address this issue of scarce HRH in LMICs by a way of strengthening the already weak referral system. [4]

The Nigerian health system operates a three-tier healthcare; primary, secondary, and tertiary. The primary health care is the entry point, and all the three-tiers are integrated through a referral system. [5] Referral is a process by which a health-care provider transfers the responsibility of the patient's management temporarily or permanently to another health professional, social worker, or community. [6] The referral system is an important component of the health-care delivery, but in this case, it is either weak or ineffective. [5]

A lot of factors have been found to be associated with this weak referral system. Shortage of HRH and material resources has been reported in a study done in Kaduna, Nigeria, [7] as a contributory factor to the weak referral system. Other studies done in sub-Saharan Africa have corroborated these findings. [8],[9] Training and retraining which are important components of HRH are largely absent in so many LMICs accounting for the weakened referral system. A study in Northern Tanzania [10] revealed that shortage of trained PHC staff was the reason for a bypass phenomenon of PHC facilities which is a common finding in LMICs. This bypass phenomenon leads to an untoward effect on referral facilities whereby they are overburdened with conditions that should have been managed at PHC facilities leading to idleness among the PHC workers and wastage of time and resources in these referral facilities. Other studies in Nigeria [11] and other LMICs have documented this phenomenon. [4],[12]

The WHO has enumerated other contributory reasons for this bypass which include loss of assurance in the health-care staff, issues of distance and transport, nonfunctional feedback system, and improperly defined referral pathways with inappropriate referral forms. [13] This study was done to assess and compare knowledge and practice of referral among an urban and rural primary health-care workers in Kaduna State, North-Western Nigeria.

  Methodology Top

The study was done in Zaria and Giwa local government areas (LGAs) in Kaduna State North-Western Nigeria, with the former being an urban LGA and the latter being a rural LGA. Zaria has a projected population of 493,782 based on 2006 Census [1] and has 13 political wards and seven health districts. The major ethnic group is Hausa-Fulani whose predominant occupations are farming and trading. It has a general hospital, 18 primary health-care centers, 16 heath centers, and 15 private clinics. All the PHCs are accessible by road throughout the year, and there is none located in a hard to reach area. The 34 health facilities in the urban LGA had a total staff strength of 485 with 208 directly involved with patient management and 37 in managing patient records. Services provided by the PHCs included outpatient, child welfare, immunization, antenatal care, postnatal, family planning, and laboratory services.

Giwa LGA had a projected population of 354,661 based on the 2006 Census, [1] with a total of 11 political wards and 11 districts. The population is predominantly Hausa-Fulani, and farming is the predominant occupation. It has a general hospital, 17 PHCs, 28 health centers and nine private clinics. The 45 government PHC facilities in the rural LGA had a total staff strength of 302 with 189 directly involved with patient management and 25 managing patient records staff. It provides same services such as Zaria LGA.

The study was a comparative cross-sectional study. The study population comprised primary health-care workers who were directly involved in either records keeping or patient management. Inclusion criteria involved all records staff, nurse-midwives, midwives, community health officers, and community health extension workers (CHEWs) working in the selected PHC facilities, a month before the study.

It was a total population study for all the PHC health-care workers who met the inclusion criteria. A total of 19 health facilities met the inclusion criteria, 8 in the urban and 11 in the rural LGAs and applying the inclusion criteria, seventy health workers in the urban and 62 health workers in the rural were studied. Hence, a total of 132 health workers were studied. The study was over a period of a month.

Mixed method was used for the data collection from the PHC staff. The qualitative data collection involved conducting a focused group discussion and key informant interviews among hospital management staff in each LGA. Quantitative data collection involved the use of questionnaire which was structured and coded and was self-administered containing close-ended questions mostly adopted from other works done on referral system. [7],[14] The adopted questions were adapted to fit the objectives of the study.

Interviews were audio recorded, transcribed, manually coded, and analyzed manually for contents in English. The coding tree focused on the identification of key themes and categories on four main areas, namely: (a) documents used to guide referral of patients, (b) materials and supplies for an effective referral process, (c) communication between staff and referred patients/caregivers, and (d) problems and suggestions for an effective referral process.

Descriptive, univariate, and bivariate analyses were carried out with IBM SPSS Statistics for Windows, Version 20.0. Released 2011. Armonk, NY: IBM Corp. Chi-square test was used to test for statistical significance of difference between urban and rural at P < 0.05. Where conditions for Chi-square were not met, Fisher's exact test was used.

Ethical Clearance

This was obtained from Ethics and Scientific Committee of Ahmadu Bello University Teaching Hospital Zaria. Confidentiality was ensured, and information on individual participant was only available to the study team. Permission was also obtained from the LGAs through the respective PHC coordinators and all the officers in-charges of the selected health-care facilities before the study was conducted.

  Results Top

A total of 132 health workers (seventy in urban and 62 in rural LGAs) were interviewed, and all the questionnaires were completely and correctly filled, giving a response rate of 100%. The health workers in both the urban and rural LGAs had a mean age and standard deviation of 34.39 ± 7.32 years in the urban and 34.31 ± 6.95 years in the rural LGA. Most of the respondents in the urban (82.9%) and rural LGAs (87.1%) were married. CHEWs constituted the greatest proportion of the respondents in both urban (41.4%) and rural LGAs (33.9%). There was no statistically significant difference in all sociodemographic characteristics of health workers in the urban and rural LGAs, except for their sex [Table 1].
Table 1: Sociodemographic characteristics of health workers studied

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Only 22.9% and 21.0% of health workers in urban and rural LGAs, respectively, had good knowledge on referral. There was no statistically significant difference in the level of knowledge on referral between the urban and rural LGAs [Table 2]. Furthermore, about one-tenth had a good practice of referral in urban (12.9%) and rural (11.3%) LGAs [Table 2]. Majority of the PHC workers in the urban (74.3%) and in the rural (67.7%) LGAs had not attended previous referral training. On referral training, there was no statistically significant difference between the urban and rural LGAs.
Table 2: Knowledge and practice of referral among health workers in urban and rural local government areas

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Key Informant Interview and Focused Group Discussion with Primary Health Care Workers in Urban and Rural Local Government Areas


Health workers were asked about the meaning of referral process; majority agreed that referral is the process of transferring a patient from primary to secondary level or tertiary level through the use of a standing order for better care. A few of them added that it also involved the use of a referral letter, which should be a two-way system and there should be a feedback. When asked to explain the document used to guide the referral process, participants listed standing order, treatment guideline, and a written format. On the issue of materials needed for effective referral process, participants listed referral forms, money, means of transportation, standing order, and proper documentation. A respondent mentioned that "staff to accompany the patient to secondary health facility, especially if patient is on intravenous line/drugs."


Participants were asked to talk about the state of referral process in their health facilities. Responses given were the referral process was not good, they lacked referral forms and registers, and they never get feedbacks. A respondent said, "we have inadequate materials; we photocopy referral form from the standing order booklet." Other responses were a lack of ambulance services, some health workers prefer not to refer patients to other hospitals due to attitude of the health workers, and some patients refuse to be referred out. Concerning communication that exists between patients and caregivers and the health workers, they gave the following responses; patients are told the importance of referral and sometimes explanation is given to patient relative, informing patients to arrange for transportation and the possibility of a staff to accompany them, allay anxiety and a respondent also mentioned that "at some time, we assist a referred patient with money."

  Discussion Top

PHCs have been identified as the entry point into the health-care delivery system. For functional referral system, the HRH at the entry point of the health-care delivery system should be trained to provide quality care.

Majority of the health-care workers were married and were in the age range 25-34 years. This is similar to a study in Brazil, [15] but different from studies in Nigeria [16] and China. [17] CHEWs constituted a significant portion of the PHC workers; this buttresses the fact that CHEWs form an important component of the HRH in the health-care delivery system particularly in sub-Saharan Africa where they are deficient. Studies around the world have reported similar finding. [15],[18],[19],[20]

Knowledge is a prerequisite for positive health worker referral behavior including the use of referral form, use of referral register, and giving feedback. The percentage of PHC that had good knowledge on referral was low in both the rural and urban LGAs. To further buttress this finding, the results from the focus group discussion (FGD) in this study also revealed that there was poor referral knowledge among primary health-care workers. A cross-sectional study on knowledge of referral conducted among primary health-care workers in Enugu, Nigeria, however, contrasts with the finding of this study, reporting generally good knowledge of referral among primary health-care workers. [21] The low percentage of primary health-care workers with good referral knowledge in urban and rural LGAs may be due to lack of training of staff on referral process; in both LGAs, about two-third of the health workers had not received training on patient referral.

It is believed that performance is associated with referral knowledge of the individual health worker, and this has been shown by some literature to be associated with training policies and improving health workers' availability and retention. [22],[23] During one of the FGD sessions, a health worker mentioned verbal referral as a mode of referral. A few PHC workers also expressed unwillingness to refer patients due to the fear of losing face before the patients. A similar observation was reported in a study conducted in rural Niger [24] where the nurses complained that they would lose integrity before the patients, if too many referrals were made, it will mean that they were not knowledgeable and will lose respect before the community. From the FGD, the PHC workers understood the definition of referral as majority mentioned that referral is the process of transferring a patient from primary to secondary level or tertiary level through the use of a standing order for better care. The study from rural Nigeria, [24] however, contrasts this finding, reporting that 96% of the health workers did not understand the basis for organizing the referral system into levels.

Practice of referral is invariably influenced by the knowledge of the PHC workers. In this study, findings from the FGD revealed that the requisite materials such as referral forms and registers were not available, and this could have accounted for why good practice of referral was only a little above one-tenth coupled with the poor knowledge the PHC workers had. This finding is similar to that of a study conducted in Tanzania [25] which reported poor referral practice where a lot of clients were thought to be eligible for referral, but only a few were referred. In the Niger study, [24] similar finding was also reported as the health workers refused to use the referral guidelines complaining that it was belittling before the patient. Other studies have reported poor qualities of referral letters including verbal referrals. [26],[27],[28] On referral communication with patient/caregiver, patients are informed about the importance of communication and sometimes their relatives are told the reason for the referral and other needed arrangements to be made. This finding contrast that from the study in Niger, [24] in which patients were simply referred without explanation or the patients were forced to accept referral by other means.

  Conclusion Top

The knowledge of referral in both the urban and the rural PHCs was unacceptably low. Beyond the problems of overloading of hospitals with inappropriate self-referrals or poorly judged referrals, barriers of distance and transport, problems of knowledge of referral among PHC workers are important factors influencing the practice of referral. There is an urgent need for a training intervention as findings revealed that less than one-fifth had received training on referral.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]

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