Understanding healthcare self-referral in Niger state (Nigeria): the service users’ and healthcare providers’ perspective

A thesis submitted to the University of Bedfordshire, in partial fulfilment of the requirements for the degree of doctor of Philosophy.Healthcare self-referral leads to patients receiving care at an inappropriate level and for an unnecessarily higher cost. The patients who most require specialist services are unable to access them in an appropriate manner and the utilisation of Primary Health Care (PHC) services are undermined. In addition, healthcare providers at the referral level regarding care are overwhelmed with minor cases that would have been easily managed at the primary care level. Despite the implications of healthcare self-referral and the large proportion (60-90%) of patients self-referring in the Nigerian healthcare system, there is a dearth of information on the factors that influence healthcare self-referral from the Nigerian context. Therefore, exploratory sequential mixed method approach was employed to address the objectives of this research which were: 1) identify the factors that influence service users’ self-referral to secondary healthcare facilities by exploring the perceptions and experiences of the service users and healthcare providers (qualitative approach); and 2) examine the relationships between the identified factors that influence the decision to self-refer among the self-referred service users (quantitative approach). Andersen’s initial behavioural model was adopted as the theoretical model for this study. This model posits that individual’s use of healthcare services is linked to their predisposing, enabling and need factors for care. Thus, the Andersen’s components helped to structure and assist with the understanding of the factors linked with healthcare self-referral. The interviews (qualitative) with the service users (n=24) and healthcare providers (n=18) were analysed using the five stages of framework analysis namely familiarisation with data, identification of thematic framework, indexing, charting, mapping and interpretation of data. This generated several themes associated with service users bypassing their primary healthcare facilities to the secondary level of care. The findings reflected perceptions regarding healthcare providers, equipment, expectations of service users, and advice from friends, relatives and others. Additional factors identified included government regulations on the utilisation of healthcare facilities, medical symptoms and the perception of severity of symptoms service users present with, in addition to an understanding of the healthcare delivery system among the service users. The inferential findings of the quantitative analysis (n=449) ascertained significant differences between levels of education and understanding of healthcare delivery. Significant differences were also established between levels of education and the perceptions of healthcare providers. Further hypotheses that demonstrated significant differences comprised the relationship between employment status and ability to access the secondary level of care. The relationship between age and reported medical symptoms among the self-referred service users was also discovered to be associated with healthcare self-referral. Additionally, the descriptive analysis also disclosed diverse levels of agreement with each of the sub-scale items on the questionnaire. Overall, the quantitative findings were observed to corroborate with large parts of the qualitative findings. The findings of this research suggest the need for a multifacet approach in addressing healthcare self-referral in the Nigerian context. This include ensuring the availability of the services of doctors within the PHC facilities, ensuring equitable distribution of equipped and operational PHC facilities. In addition, there is need to educate the populace on the appropriate utilisation of the different levels of healthcare facilities. In conclusion, an original approach to healthcare self-referral was demonstrated by adopting the exploratory sequential mixed method and Andersen’s model to understand healthcare self-referral. The findings also contribute to this field by examining the relationships between the factors identified to predict healthcare self-referrals and consequently, offer recommendations, as it applies to the healthcare system in Nigeria