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

The file attached to this record is the author's final peer reviewed version.Background: The distortion of the pyramidal structure of the healthcare delivery system due to by-passing 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 minutes on average. This was subsequently transcribed verbatim 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