To our knowledge this is the first study assessing the outcome of referrals by CHWs to PHC clinics in an urban township area in sub-Saharan Africa. Overall for 70% (104/148) of infants referred by CHWs the outcome of the referral could be confirmed. Amongst interviewed mothers, 95% of referrals of infants by CHWs during the first 12 weeks of life were completed, which is much higher than reported elsewhere in Africa
[19, 20] and South Asia
Most referrals were for neonates (62% between birth and 4 weeks of age), a critical period for timely referral to prevent death. Furthermore, most referrals were for respiratory problems which are a major cause of neonatal death in low and middle income countries.
A number of factors could potentially have contributed to the high referral completion rate in our study: firstly, Umlazi health facilities are easily accessible, most within walking distance. A study in Zambia also found that proximity to health facilities contributed to improved referral completion
. Secondly, CHWs were carefully selected and resided within their communities and this enhanced trust, respect and communication with caretakers. Thirdly, the use of referral letters resulted in less waiting times for most mothers. Kallander et al. in a case series study on referral in home management of malaria in Western Uganda indicated that use of referral slips and “counter referral” slips could contribute to improved referral compliance
. Finally, intensive training and field supervision of CHWs with weekly contact sessions for mentoring might have increased CHW counselling and assessment skills. The finding of high referral completion within an urban township context is encouraging in light of the current national Department of Health plans to formalise CHW involvement in the health sector. This result is an indication that mothers do respect CHW judgement and advice.
This study found a referral rate of 6% amongst the study cohort which is lower than the generally expected rate of around 10 to 15%. The reason for this lower referral rate could be that this study captured CHW referrals during the first 10 weeks after birth only (CHWs conducted home visits during the first 10 weeks after birth). Another plausible reason could be that a newborn illness is an emergency; it is possible that the neonates were taken to health facilities before CHWs conducted a home visit and these were not included in the CHW referrals.
We found that most mothers delayed more than 12 hours before completing a referral following CHW advice. Even a few hours delay can be fatal, especially in the early weeks of a baby’s life. In South Africa child deaths are audited as part of the Child Health Identification Programme. A death audit at King Edward Hospital in Durban found that 25% of child deaths were due to modifiable factors such as delay in seeking care and failure to realize the severity of illness
. In our study mothers cited not recognising the seriousness of illness and closed clinics as reasons for delays in consulting. Delays of up to 7 days were reported in western Nepal, Cambodia and western Uganda in health care seeking, with lack of money commonly mentioned as a cause for delays
[23–25]. In contrast to other studies
[26, 27] we found that transport was not a barrier to referral completion in a context where the majority of mothers could walk to a facility.
In our study all mothers who did not complete referral reported that they failed to identify danger signs. It is possible that according to mothers’ judgement, infant illnesses may not have been viewed as serious. A study in western Nepal found that maternal perceived severity of illness was an important factor influencing care-seeking behaviour
. A longitudinal community-based study on mothers’ health-care seeking in South West Ethiopia found that mothers adopted a wait-and see attitude, hoping symptoms would resolve on their own which delayed consulting
We found that less than a quarter of health workers gave feedback to the CHW on the outcome of the referral. Similar results of lack of formal written feedback were reported by Siddiqi et al. in Pakistan who found that none of the higher level facilities sent feedback on the outcome of referrals back to first level care facilities
. Poor feedback to CHWs following referrals is cause for concern given that the Department of Health is proposing to develop family health teams of CHWs linked to health facilities.
Our study had several limitations. Selection bias might have been introduced due to the numbers of mothers who were lost to follow up due to relocation or denying receiving referrals despite being on the lists. Recall bias might have occurred as events under study occurred between 2 weeks and 18 months prior to the interview. To address this, data from participants interviewed more than six months following referral were analysed separately to assess the potential for recall bias before pooling all data. Since severe illness or hospitalisation of an infant is a fairly major family event we do not anticipate that recall bias posed a meaningful problem.