Determinants of self-driven referral among clients seeking outpatient services at Bungoma County Referral Hospital, Kenya

Abstract

Self-referred cases, where patients do not visit primary healthcare (PHC) facilities and instead consider visiting higher-level hospitals, create a negative burden on the healthcare system and jeopardise the attainment of the universal health coverage (UHC) requirements of the Sustainable Development Goal (SDG) 3.8. The prevalence of self-referral has been estimated at 84.3% in Kenya, and Bungoma County Referral Hospital (BCRH) has overutilisation, which is explained by systemic PHC gaps; however, there is a paucity of empirical studies that explain the determinants of overutilisation. This research evaluated the factors that have an impact on self-referrals in outpatient clientele visiting BCRH. Using the Health Belief Model (HBM), the research operationalised the concept of self-referral by the severity of perceived illness and mistrust in PHC and perceived benefits of care at a higher-level facility. An analytical cross-sectional design was used. The study population was 1,880, with a prevalence of 84.3%, which has a sample size of 201 patients in the Outpatient Department, Antenatal Care, Mother and Child Health, and Family Planning clinics. Purposive sampling identified key informants and systematic random sampling patients. Information was obtained through a pre-test validity structured questionnaire and key informant interview (KII) guide; quantitative data were analysed with chi-square tests and odds ratios (p < 0.05) using Statistical Package for Social Sciences version 27, and qualitative data were done through thematic analyses. Findings showed that self-driven referral rate in BCRH was 51.7%. Out of the 201 respondents, 71.6% were female, 73.2% were below 32 years of age and 60.2% were secondary education holders. Propensity toward self-referral was stronger among male clients (Odds Ratio [OR] = 4.418, p = 0.040) as well as those having tertiary education (OR = 0.094, p = 0.006). This study concludes that the factor of self-motivated referral in Bungoma County can be highly influenced by the systemic inadequacy of PHC, especially the insufficiency of diagnostics and the availability of medication and is also exacerbated by gender and educational gaps. This study recommends strengthening of PHC infrastructure, the guaranteeing of continuous medication availability, the coordination of insurance requirements with referral policies and the building of trust in communities asthe necessary steps in reducing unnecessary self-referrals and promoting UHC.