HD Kalter1, R Salgado2, LH Moulton3, P Nieto4, A Contreras2, ML Egas4, RE Black1

1Department of International Health, Johns Hopkins University Bloomberg School of Public Health,Baltimore, MD, USA;2The BASICS Project, Rosslyn, VA, USA;3Departments of International Health and Biostatistics, Johns Hopkins University Bloomberg School ofPublic Health, Baltimore, MD, USA;4Universidad Tcnica del Norte, Ibarra, Ecuador.R Salgado is currently with John Snow, Inc., Arlington, VA, USA.

Short title: Referral constraining factors for severely ill children

Corresponding author: H.D. Kalter, Department of International Health, Johns Hopkins University Bloomberg School ofPublic Health, 615 North Wolfe Street, Room E8132, Baltimore, MD, 21205, USA. E-mail hkalter@jhsph.edu. Tel +1410 955 3928. Fax +1 410 614 1419.

HD Kalter designed and helped develop the study, helped analyze the data, and wrote the paper.

R Salgado helped design and develop the study, and contributed to the writing of the paper.

LH Moulton conducted the statistical analysis and contributed to the writing of the paper.

P Nieto helped develop the study and analyze the data, managed the project, and contributed to the writingof the paper.

A Contreras helped develop the study and analyze the data, and contributed to the writing of the paper.

ML Egas supervised the project and contributed to the writing of the paper.RE Black helped develop the study and contributed to the writing of the paper.

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Kalter HD, Salgado R, Moulton LH, Nieto P, Contreras A, Egas ML, Black RE. Factors constrainingadherence to referral advice for severely ill children managed by the Integrated Management ofChildhood Illness approach in Imbabura Province, Ecuador. Acta Paediatr 00, Stockholm. ISSN 0803-5233

Aim: Low referral completion rates in developing countries undermine the Integrated Management ofChildhood Illness (IMCI) strategy for lowering child mortality. We sought to identify factorsconstraining adherence to referral advice in a health system using the IMCI approach.

Methods: We prospectively interviewed caregivers of 160 children urgently referred to hospital.Caregivers who accessed and did not access hospital were compared for potential referralconstraining factors, including demographics, family dynamics, the severity of their childs illness, theirinteraction with the health system, self-perceived problems, and physical and financial access.

Results: 67/160 (42%) referred children did not access hospital. 6 factors were associated with non-access, including 2 health worker actions: not being given a referral slip (adjusted odds ratio[OR]=15.3, 95% confidence interval [CI]=4.4, 64.6) and not being told to go to the hospitalimmediately (adjusted OR=5.3, 95% CI=1.9, 16.3). Receiving both these interventions reduced therisk of not accessing hospital to 19%, from 96% for those who received neither intervention. Severalindicators of illness severity, including caregivers ranking of their childrens illness severity, thepresence of severe illness signs, and mortality, were investigated and found to not be importantexplanatory factors.

Conclusion: Providing a referral slip and counseling the caregivers of severely ill children to go to thehospital immediately appear to be powerful tools for increasing successful referral outcomes.

Key words: Integrated Management of Childhood Illness, IMCI, referral, referral constraints

#The World Health Organization (WHO) and UNICEF in 1992 launched the Integrated

Management of Childhood Illness (IMCI) approach to providing health care and reducing themortality of young children. The IMCI provides case management guidelines that assist healthworkers at first-level facilities to diagnose and manage the conditions thought to beresponsible for 70% of child deaths in less developed countries (1), including serious bacterialinfection, diarrhea, and low weight or feeding problems in young infants from 1 week up to 2months of age; and pneumonia, diarrhea, malaria and severe febrile illnesses, ear problems,malnutrition and anemia in older infants and children from 2 months up to 5 years old.

A key strategy of the IMCI approach is the identification and urgent referral to hospital ofseverely ill infants and children. (Alternative guidelines are provided for areas where referral isnot possible.) Studies have found the guidelines to have good to moderate sensitivity fordetecting children who require hospital admission (2,3,4,5). However, the success of the IMCIreferral strategy depends on additional factors. Health workers must actually refer theseverely ill children identified by the guidelines. In addition to their level of clinicalcompetence, health workers referral behavior may be influenced by their assessment ofwhether a childs caregiver is likely to follow their advice, and by the quality of communicationbetween first-level and referral facilities in the health system (6,7). It is also possible thathealth workers may judge some referable children to be less severely ill than others and, insuch cases, reduce their counseling efforts or otherwise modify their referral practices. TheIMCI training curriculum attempts to overcome these problems by instructing health workersin a standardized counseling method for the mothers of all referred children (8). This includesexplaining the need for referral, helping the mother to identify and overcome barriers toadherence, and providing a referral note for the mother to take to the hospital.

Once a child is referred, the final step to a successful outcome is that the caregiver bothaccepts the referral and is able to access the hospital. Recently documented referralcompletion rates of from 24% to 48% (9,10,11) point to the difficulties of achieving thisobjective. Furthermore, few studies have assessed which factors are most likely to constrainadherence to referral advice for severely ill children, and thus should be emphasized by theIMCI training. Constraints that have been identified include female gender of the sick child(10), caregivers anxiety about the hospital (12,13), their perceived low severity of the illness,their other childcare responsibilities, needing their husbands permission to make the journey,associated costs and illiteracy (13), and health workers poor communication skills (12).However, other than female gender, all these constraints were identified by purely descriptivemeans.

In addition, 3 comparative studies identified barriers to seeking medical care for non-fatal(14) and fatal child illnesses (14,15,16). However, careseeking constraints are likely to differfor caregivers who have already entered the formal health care system, and careseekingbehavior may be altered by the act of referral itself. Health worker training in the use of casemanagement guidelines and health systems changes undertaken by districts using the IMCIapproach may also affect the referral advice given to caregivers. The present study sought toidentify modifiable factors that constrain adherence to referral advice, in a setting where theIMCI approach has been fully implemented and hospitals are geographically accessible. Thelevels of several key referral indicators in this setting were also assessed.

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Study Setting and Health ServicesImbabura Province is located in the plateaus and highlands of the Andes Mountains innorthern Ecuador. The 1998 under-5 years old population was reported as 40,807 (17) andthe corresponding official 1996 mortality rate, which is thought to be undercounted by about20%, was 38.6/1000 births (18). The population is poor overall, but 88% of women with achild under 2 years old are literate (19). Paved roads connect most villages to the majortowns, but high mountain passes, rain and mud slides can make the roads impassable attimes. Public buses run between the villages and towns, but are scheduled in remote areasonly once or twice per day at most. The Ministry of Public Health (MOH) operates 53 first-level facilities and 4 hospitals in the province. Most first-level facilities are centrally locatednear the major towns, but there are also several sub-centers and health posts in the outlyingareas. The 4 hospitals are all centrally located.

The IMCI approach was implemented in the province in 1996-1997. All physicians, nursesand nurse auxiliaries working in the MOH facilities were trained in the use of the guidelines.To prepare for the present study and to help assure that children meeting referral criteria wereidentified and referred, all health personnel were informed about the studys purpose andunderwent refresher training in the use of the IMCI guidelines. During the study, there was noadditional supervision of the health workers application of the guidelines, including theircounseling of caregivers to help identify and overcome referral constraints or their providing areferral slip, beyond that normally accorded by the health care system.

Study DesignThe study was conducted from September 1, 1999 to April 30, 2000 in 51 of the 53 MOH first-level facilities and in all 4 hospitals. All children from 1 week up to 5 years old seen at a first-level facility with an IMCI diagnosis were registered in a study log that included the type ofprovider seen and the childs age, sex, diagnosis and referral status. Study logs were alsokept at the 4 hospital emergency departments, in which were recorded the children seen withan IMCI diagnosis and each childs referral (referred by an MOH facility or not) and admissionstatus.

The interviewers were young, Ecuadorian women who had completed at least theirsecondary education and had prior experience in administering structured interviews. Theytracked the children who were urgently referred to hospital for an IMCI diagnosis, with anattempted follow-up period of 24 hours after the referral. The interviewers first searched thehospitals, and if a referred child was not located the interviewer next went to the home. Allstudy subjects were read an approved informed consent statement and gave their consent toparticipate in the study.

A structured questionnaire was used to ask caregivers about their childs illness, relatedcareseeking, and 6 categories of potential referral constraining factors: demographics andsocioeconomic status; family dynamics related to decision-making; indicators of illnessseverity; the caregivers interaction with the health system, including her prior experience withthe referral hospital and any counseling provided by the first-level health worker about thecurrent illness; the caregivers perceived problems in accessing the hospital; and possiblephysical and financial barriers, including geography, transportation and costs related to theillness. Following the interview, caregivers of children who had not yet accessed the hospitalwere offered assistance in reaching the hospital at that time.

%The study underwent ethical review and was approved by the National Institute of

Scientific Research and Technological Development of the Ecuador Ministry of Public Health,and by the Committee on Human Research of the Johns Hopkins University BloombergSchool of Public Health.

Statistical AnalysesReferral indicators were calculated from the numerator and denominator data recorded in thestudy logs. Referral indicators included the percent of children seen at a first level facility withan IMCI diagnosis who were urgently referred, the percent of the referred children whoaccessed hospital, and the percent of the referred children who accessed hospital who wereadmitted.

Potential referral constraining factors were compared for the referred children who hadaccessed and not accessed hospital by the time of the follow-up interview. Any variable withan unadjusted odds ratio >1.5 or

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Subjects and Referral IndicatorsFrom September 1, 1999 to April 30, 2000, there were 11,668 visits to the 51 first-level studyfacilities by children 1 week up to 5 years old with an IMCI diagnosis; 6181 (53%) of the visitswere by males, and 5487 (47%) were by females. One hundred seventy (1.5%) of thechildren were urgently referred to hospital from 43 of the 51 first-level facilities. The referralrate ranged from 0.0% to 6.2%. Eight referred children were lost to follow-up and 2 more diedbefore the interview could be conducted.

The caregivers of 160 referred children were interviewed; 67 (41.9%) of the children didnot access hospital, and their caregivers were interviewed with a median follow-up time afterthe referral of 2 days (range, 0-9). The 93 referred children who accessed hospital did sowithin a median time of 0 days (range, 0-3), and 67 (72%) of these children were admitted.The caregivers of 53 admitted children were interviewed in the hospital with a median follow-up time of 1 day (range, 0-12). The caregivers of the other 14 admitted children plus the 26who accessed hospital but were not admitted were interviewed outside of the hospital with amedian follow-up time of 2 days (range, 0-8).

A companion study of childhood deaths in the province during the same 8-month studyperiod determined that 11 (6.9%) of the 160 referred children died from their acute illnessafter the interview had been completed. This included 7/93 (7.5%) and 4/67 (6.0%) of thechildren who, respectively, did and did not access hospital (OR 1.28, P=0.76). The 2 childrenwho died before the referral interview could be conducted were captured by the mortalitystudy; 1 child had accessed a hospital and the other had not.

Table 1 shows some basic characteristics of the 160 referred children and their families.The families were poor and the childrens caregivers had little formal education. Mostcaregivers did not work outside of the home. Relative to expected disease severity by agegroup, young infants were under-represented among the referred children. This reflected theage distribution of the children seen at the first-level facilities with an IMCI diagnosis: 480(4.1%) of the 11,668 visits were by infants from 7 days up to 2 months old. As shown by thechilds birthplace, almost 1/3 of the families had some prior experience with a hospital. Themedian time it took the caregivers to reach a hospital by their preferred transportation methodsuggests that physical access is not a major constraint in this setting.

Referral ConstraintsNineteen potential referral constraining factors, with at least 1 variable in each of the 6categories of factors examined by this study, achieved a required cutoff level for inclusion inthe multivariate analysis (Table 2). All but 2 of these factors, fathers education less than 2years and caregivers work obligations were positively associated with not accessing ahospital. Some types of variables were asked about in multiple ways in order to assess boththe caregivers perception of the potential problem as well as to try to determine the factualbasis for a constraint. For example, caregivers were asked if the transportation cost to reachthe hospital was a problem for them, and they were asked the actual travel cost to thehospital. The signs included in caregiver did not report a severe illness sign were based onthe IMCI guidelines, as well as signs that are alarming to caregivers in Ecuador. For example,groaning (quejaba) is a sign of grave illness meaning that the child is too weak to emit strongpain sounds. All the signs were spontaneously reported in response to an open-endedquestion.

'Variables that did not reach the threshold for entry into the multivariate analysis

included, among others, month of the year, childs gender, childs birthplace (home orhospital), caregivers education, caregivers work outside the home, fathers occupation,household crowding, caregivers other childcare responsibilities, seeking non formal healthcare (friend, neighbor, pharmacy, traditional healer) before going to the first-level facility,caregivers not ranking the illness as severe before seeing the first-level health worker,illness duration, and all costs related to the illness other than those for transportation to thehospital and for food and lodging while at the hospital. Some of these factors were commonproblems but were similar for caregivers who accessed and did not access hospital. Forexample, 70/93 (76%) and 51/67 (75%) caregivers who, respectively, did and did not accesshospital said that the hospital costs were a problem for them (OR 1.05, P=0.92).

Table 3 shows the logistic model, consisting of 6 risk factors, which was most highlypredictive of not accessing referral care. First-level health workers giving a referral slip andadvising caregivers to go to the hospital immediately had a strong multiplier effect on eachother, such that receiving both interventions versus receiving neither decreased a childs riskof not accessing hospital from 96% to 19% (p1.50 (Table 2). The type of health worker (physician vs. other) who saw the child did notmeet the required statistical threshold for inclusion in the logistic regression. Nevertheless, weincluded it due to the concern that physicians might use their own diagnostic criteria beyondthe IMCI guidelines and refer only the most severely ill children. However, once first-levelhealth worker did not give a referral slip and first-level health worker did not say "Go to thehospital immediately" came into the stepwise-constructed logistic model, all 3 severityvariables were prevented from entering the model.

The results from the random effects logistic regression models showed that there was nosignificant clustering by health facility of these interventions. The p-values for first-level healthworker did not give a referral slip and first-level health worker did not say "Go to the hospitalimmediately" were 0.36 and 0.11, respectively, even without adjustment for any other facility-level covariates such as patient mix.

(High Risk Sub-GroupsWe explored the impact of being given a referral slip and counseling to go to the hospitalimmediately on the 2 high-risk sub-groups identified by the analysis. Receiving both theseinterventions, versus receiving neither, decreased the risk of not accessing hospital from100% to 16% (p

)

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It is common in less developed countries for a large percentage, often the majority, of childrenreferred from first-level health facilities to not access hospital. This undermines theeffectiveness of health systems in general, and more specifically of the IMCI approach that isbeing widely implemented in less developed countries. A significant part of IMCIs impact onmortality will come from mothers accepting the referral and taking their children to a higherlevel facility for care. The WHO IMCI training curriculum instructs health workers to give themothers of all referred children a referral note and to help them identify and overcome barriersto accessing the hospital. However, data from Kenya show that of all the skills taught by IMCItraining, health workers performed least well in counseling (24).

Health Worker ActionsThe present study found that giving a referral slip and advising caregivers to go to the hospitalimmediately after departing the first-level facility greatly increased the likelihood that urgentlyreferred children would access hospital. These interventions multiplied each others effect toincrease successful referral outcomes. Prior researchers have documented the proportion ofreferrals from first-level care to hospital that are written (6), but have not evaluated the impactof giving a referral slip on caregiver behavior. Previous work has also shown that poor healthworker interpersonal communication skills can decrease the referral completion rate (9,12),but the impact of specific messages, such as to go to the hospital immediately, has not beenexamined. Other counseling efforts assessed by our study, such as helping caregivers toovercome barriers to hospital entry and explaining the childs diagnosis to the mother, werenot as effective in ensuring a successful referral.

Illness SeverityPerception that an illness is not severe has been shown to delay seeking of formal medicalcare (14) and the response to a referral directive (11). In our study, caregivers ranking ofillness severity was increased by the visit to the first-level facility, and was related to receivinga referral slip and being counseled to go to the hospital immediately, but was independent ofcaregivers response to the referral advice. Even caregivers who did not perceive their childsillness to be severe were more likely to access the hospital if they were given a referral slipand told to go immediately after leaving the first-level facility. Three additional severityindicators, including health worker category, severe illness signs, and mortality, wereinvestigated and also found to not be important explanatory factors.

Young Infancy and Staying OvernightAnother referral constraint that might be amenable to counseling by health workers wasidentified. Children whose caregivers had to spend the night away from home in order tocomplete the referral were at increased risk of not being taken to hospital. Infants youngerthan 2 months old whose caregivers had to stay overnight faced a particularly high risk. Beinggiven a referral slip and told to go to the hospital immediately was sufficient to overcame thisrisk in the older infants and children, but these interventions did not modify the risk for theyoung infants. De Zoysa et al previously found that mothers were reluctant to take their younginfants to hospital after referral, and felt that this was at least partly due to concern for theirspecial vulnerability (11). This descriptive study was conducted in a setting with anunspecified but apparently unacceptable distance of available hospitals from the community,

so many of the caregivers would likely have had to stay overnight in order to complete thereferral. Their reluctance, and that of the caregivers in our study, could be due to concern fortheir young infants frailty but might also indicate less willingness to expend additionalresources for their care.

The mothers in de Zoysa et als study mentioned transportation cost and needing theirhusbands support and permission to make the journey as additional barriers to completing areferral (11). However, Bhandari et al found a referral acceptance rate of only 24% for younginfants in the same setting, despite an offer of free transportation and hospital care (8). In ourstudy, most caregivers of young infants who had to spend the night away had a problem withtransportation cost and were not the decision-maker about seeking referral care, but thesample size was too small to draw any firm conclusions about these possible constraints.Further research is needed to identify appropriate counseling messages that might overcomethe referral constraints for young infants whose caregivers must stay overnight in order toaccess the hospital.

Other Referral ConstraintsThe mother not being the decision-maker about hospital care, and transportation cost, weresignificant referral constraints for our study group as a whole. De Zoysa et als study of younginfants supports these results, as does Terra de Souza et als finding that transportation costsdelayed the first seeking of formal medical care for fatally ill postneonates (14). Theseconstraints are unlikely to respond to health worker counseling. Health messages could bedeveloped to educate men about the importance of womens decision making for childrenshealth care, and transportation cost might be attacked by a multi-sector intervention. Othercosts that we examined, including all the pre-hospital costs and the caregivers self-perceivedproblems with hospital costs, were not associated with decreased access to hospital.

We did not find certain referral constraints that have previously been identified, includingfemale gender (10), anxiety about the hospital, other childcare duties and illiteracy (11). Morefirst-level (6,181/11,668 or 53%) and hospital (1,385/2,466 or 56%) visits in our study were formales, but this could reflect differential illness rates. There were signs of anxiety about thehospital in our study group. First-level health worker did not discuss how to gain entry to thehospital and caregiver did not feel she could explain her childs illness to a hospital doctorwere risks for not completing the referral before adjustment for other variables. This anxietymay often have been overcome by prior experience: 51 children were born in a hospital and,of 37 caregivers who had taken their child to the local MOH hospital in the past 3 years, 20(54%) were satisfied with the care they received. In the end, only 25/160 (16%) caregiverssaid they were dissatisfied with the available hospital, and 9 of these completed the referralanyway.

Other childcare responsibilities was also eliminated as a referral constraint by our use ofa comparative methodology: 45% of caregivers said this was a problem for them, but this wassplit between the 39/93 (42%) who completed and 33/67 (49%) who did not complete thereferral (OR 1.34, P=0.45). There was also no difference between the number of childrencared for by those who did (median 2, range 06) and did not (median 2, range 07) completethe referral (P=0.71). We did not directly measure literacy among our study group, but even'caregiver's education less than 2 years' did not increase the risk for not completing thereferral. In de Zoysa et al's study in India, illiteracy had very practical consequences, such asthat mothers could not read the bus numbers (11). Literacy may be less important to referralcompletion in the environment faced by mothers in Ecuador.

Study LimitationsPossible limitations of the study included a caregivers response bias. Caregivers of childrenwho did not reach hospital and whose condition had worsened at the time of the interviewmight have tended to exaggerate the problems they faced in seeking hospital care. However,only 8 children were reported to be feeling worse at the time of the interview and only 2 ofthese had not accessed a hospital. Another possible bias was that health workers might havemodified their actions for mothers of referred children whom they judged to be less severelyill. Health workers might also have concluded from their interaction with caregivers whetherthey intended to complete the referral and, if this was seen as unlikely, withheld a referral slipif these were in short supply. We were able to assess the potential bias related to judgementof illness severity. The distributions of severe illness signs and mortality among the childrenwho did and did not receive a referral slip and counseling to go to the hospital immediatelysuggest that the health workers did not treat referred children differently based on their illnessseverity. A final limitation is that the study findings may not be fully generalizable to othersettings where, for example, the road system is less developed and geographic access maytherefore be more difficult.

Conclusions42% of the referred children in this study were not taken to hospital, despite the fact that as agroup they were very sick: 6.9% died from their illness, and 72% of those who accessed ahospital were admitted. Six factors were associated with not completing the referral, and thefindings suggest that health worker training in referral counseling should be strengthened.Health systems should ensure that referral slips are available, and emphasize to healthworkers that they should give a slip and counsel the caregiver of each urgently referred childthat the severity of the illness requires going to the hospital immediately after leaving the first-level facility. Health workers should be made aware that young infants whose caregivers mustspend the night away from home in order to complete the referral might be at particularly highrisk of not reaching the hospital. They should be trained to assess and address thisconstraint. Other referral constraining factors identified by the study, such as transportationcost and the mother not being the primary decision-maker regarding hospital care, may beless amenable to intervention by the health system.

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This work was supported by the US Agency for International Development through the JohnsHopkins Family Health and Child Survival Cooperative Agreement and through the BASICSProject.

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WHO/UNICEF. The WHO/UNICEF Approach to Integrated Management of the Sick Child.Geneva: WHO; 1995

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%Table 1. Characteristics of 160 referred children and their families,Imbabura Province, Ecuador, September 1, 1999April 30, 2000Characteristic N (%)Childs age 7 days -1 month

2-11 months1-4 years

25 (15.6)65 (40.6)70 (43.8)

Childs gender MaleFemale

93 (58.1)67 (41.9)

Childs birthplace Home Hospital

OtherUnknown

102 (63.8)51 (31.9)6 (3.8)1 (0.6)

Childs caregiverEducation median years (range)Work outside the home median hours/week (range)Mother

160 (100.0)4 (0-14)0 (0-63)

149 (93.1)Household

Water supply No indoor waterFloor material EarthenPersons/sleeping room median (range)

123 (76.9)82 (51.3)

4 (1.7-11.0)Time to reach a hospital median minutes (range) 30 (3-360)

&Table 2. Potential factors constraining adherence to referral advice, withan unadjusted odds ratio >1.5 or

'Table 3Logistic regression model, showing the adjusted odds ratios, 95% confidence intervalsand exact p-values of the factors most highly predictive of not accessing hospital

Referral constraining factors Odds ratio 95% CI Exact PFirst-level health worker did not give a referral slipTransportation cost to access hospital >0 sucresFirst-level health worker did not say "Go to the

hospital immediately"Mother not the decision-maker about seeking

referral careCaregiver must stay overnight to access the

hospital, and childs age 2 months

15.3 6.4

5.3

5.0

79.2

7.0

4.4 - 64.6 1.4 - 38.6

1.9 16.3

1.7 - 15.7

7.4 1,429.5

1.8 34.0

(

Tabl

e 4

Mu

ltipl

ier e

ffect

o

n ad

here

nce

to re

ferr

al ad

vic

e o

f hea

lth w

ork

ers

givin

g ca

rgiv

ers

a re

ferr

al s

lip an

d co

un

selin

gth

em to

go

to th

e ho

spita

l im

med

iate

ly (no

t adju

sted

for o

ther

re

ferr

al co

nst

rain

ing

fact

ors

); an

d th

e di

strib

utio

ns o

f sev

ere

sym

ptom

s an

d de

aths

am

on

g th

e re

ferr

ed ch

ildre

n

Deat

hs

Acce

ssed

hosp

ital

N (%)

Did

not

acce

ssho

spita

l

N (%)

Seve

resy

mpt

oms

N (%)

N ( %)

Illne

ss d

urat

ion

afte

r th

e vi

sit

Med

ian

(ran

ge)

Firs

t-lev

el h

ealth

wor

ker

said

"Go

to th

eho

spita

l imm

ediat

ely"

65 (81.3

)15 (18

.8)

30 (37.5

)5 (6.3)

5(1

15)

Firs

t-lev

el h

ealth

wor

ker

gave

aRe

ferr

al s

lip

Firs

t-lev

el h

ealth

wor

ker

did n

ot s

ay "

Go

toth

e ho

spita

l imm

ediat

ely"

19 (55.9

)15 (44

.1)

6(17

.6)

4(11

.8)

12 (229

)

Firs

t-lev

el h

ealth

wor

ker

said

"Go

to th

eho

spita

l imm

ediat

ely"

7(43

.8)

9(56

.2)

6(37

.5)

0 (0.0)

Fi

rst-l

evel

hea

lthw

orke

r did

not

give

a re

ferr

alsli

pFi

rst-l

evel

hea

lth w

orke

r did

not

say "

Go

toth

e ho

spita

l imm

ediat

ely"

1 (3.6)

27 (96.4

)8

(28.6

)2 (7.1)

5.5

(38)

)

Tabl

e 5.

Impa

ct o

n ad

here

nce

to re

ferr

al a

dvic

e o

f firs

t-lev

el h

ealth

wo

rker

sgi

vin

g ca

regi

ver

s a

refe

rral

slip

and

cou

nse

ling

them

to

go

to th

e ho

spita

lim

med

iate

ly,

in c

hild

ren

2 m

on

ths

old

who

se c

areg

iver

sm

ust

sta

y o

ver

nig

ht (n

ot ad

juste

d fo

r oth

er re

ferr

al c

onst

rain

ing

fact

ors)

Acce

ssed

hosp

ital

N (%)

Did

not

acce

ssho

spita

lN (%

)Fi

rst-l

evel

hea

lth w

orke

r sa

id "G

o to

the

hosp

ital im

med

iatel

y"an

d ga

ve a

refe

rral

sli

p2

(28.6

)5

(71.4

)Fi

rst-l

evel

hea

lth w

orke

r did

not

say "

Go

to th

e ho

spita

lim

med

iatel

y" an

d ga

ve a

refe

rral

sli

p0 (0.0)

1(10

0.0)

Firs

t-lev

el h

ealth

wor

ker

said

"Go

to th

e ho

spita

l imm

ediat

ely"

and

did

not g

ive a

re

ferr

al s

lip0 (0.0)

2(10

0.0)

Care

giver

mus

t sta

yov

erni

ght to

acce

ssho

spita

l, and

Child

s ag

e

2 m

onth

sFi

rst-l

evel

hea

lth w

orke

r did

not

say "

Go

to th

e ho

spita

lim

med

iatel

y" an

d di

d not

giv

e a

refe

rral

sli

p0 (0.0)

22(10

0.0)