Factors Associated with Delayed Referrals of Patients with Sepsis from Primary to Tertiary Healthcare in Blantyre, Malawi: A Qualitative Study

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Sepsis is a life-threatening condition that requires prompt identification and early definitive medical intervention. Globally, sepsis is common, with estimated 31.5 million cases per year. Sepsis accounts for a significant in-hospital mortality rate of 17% in high-income countries while in Malawi, it ranges from 17–50%. For Malawi, the trend can be reversed with improvements in patient referral system within the healthcare system. The study set out to establish the referral pathway of patients with sepsis from primary healthcare to tertiary hospitals and to understand healthcare workers and patients’ perspectives on barriers associated with delayed referral of patients with sepsis from primary to tertiary healthcare. Methods A qualitative descriptive study in six health centres within Blantyre District health office included 22 face-to-face semi-structured interviews with purposively selected patients recovering from sepsis and with healthcare workers. Results The study revealed that the main referral pathways for patients with sepsis include community-to-facility and facility-to-facility referrals. Ambulances and personal transport are common transportation mode used during referrals. Primary care facilities face several challenges that delay referrals from primary to tertiary health facility of patients with sepsis, such as lack of referral transport, poor communication, poor road network, shortage of skilled healthcare workers, patient preferences, delayed treatment-seeking action, and ambulances prioritising maternal conditions. Conclusions Patients’ delay and failure to access prompt and timely referral services result from the healthcare system’s lack of transport, communication problems, bad road networks and shortage of well-trained personnel. Referral delays have deleterious effects on patient-care outcomes. Sepsis Referral pathway Primary health care Tertiary hospital Delay referral Background Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, is a significant global health concern[ 1 ]. Its related deaths account for 19.7% of all global deaths annually [ 2 ]. Most of the worldwide burden of sepsis occurs in low- and middle-income countries (LMICs), where nearly 85% of an estimated 48.9 million annual cases of sepsis occur (WHO 2020 In 2017, sepsis incidence and mortality varied substantially across regions, with the highest burden in Africa, Oceania, south Asia, east Asia, and southeast Asia[ 3 ]. Itis a life-threatening illness that requires prompt identification and early definitive medical intervention [ 1 ]. Sepsis is likely under-recognised in African countries due to limited diagnostic competence, varied reporting, and a lack of universal death registers [ 4 ]. In high-income settings, outcomes are improving because of the comprehensive application of an expanding evidence base for early recognition, rapid administration of appropriate antimicrobials, and aggressive fluid resuscitation, paired with intensive physiology monitoring and organ support provision [ 5 ]. Malawi's intensive care units are responsible for 40% of the mortality [ 6 ]. In Malawi, severe cases of sepsis are referred to tertiary health facilities for specialist care. However, sepsis cases are frequently diagnosed too late, resulting in a high sepsis-related in-hospital mortality of between 17 and 50 percent [ 7 ]. This study sheds light on the barriers to timely referral of patients with sepsis and lessons to prevent referral delays to improve patient outcomes. Theoretical frameworks This study categorised the collected data using the adopted “Three Delays’ theoretical framework[ 8 ]. The Three Delays Model has been widely applied to understand maternal mortality but it has not been systematically applied to the context of medical conditions more broadly. This model could serve as a useful framework for establishing factors associated with delay referral of medical conditions including sepsis to one level of care to another referral hospital. The study discovered that the three delays described by Thaddeus and Maine (1994) were delays in seeking, reaching, and receiving care[ 9 ]. METHODS Research Design This cross-sectional qualitative descriptive study comprised in-person in-depth interviews (IDIs) with two participant groups: patients recovering from sepsis and healthcare workers (HCWs). This study was conducted at six Blantyre District Health Office (DHO) health centres selected randomly, namely, Madziabango, Pesulu, Lirangwe, Bangwe, Ndirande, and Zingwagwa health centres. Sampling procedure A total of 22 participants were purposively sampled and interviewed. The final sample size was determined through saturation; thus, until the information collected from each subsequent interview was repeated [ 10 ]. A simple random sampling method (casting of lots) was used to select three urban and three rural primary healthcare centres from the Blantyre District Health Office (DHO) [ 11 ]. Inclusion criteria were adult patients referred from the health centre to Queens Elizabeth central hospital (QECH)with sepsis and discharge and recovering at home and Health care workers providing direct and indirect care of patients with sepsis. Data Collection Data were collected using a semi-structured interview topic guide containing questions that elicited free responses. After obtaining written consent, patient interviews were conducted in the local language (Chichewa), whereas interviews with HCWs were conducted in English or Chichewa, depending on the interviewee’s preference. The interviews were conducted in a private room within the health facility. The interviews were conducted between 1 May 2023 and 16 May 2023, with ten patients (6 males and 4 females) and 12 HCWs (9 females and 3 males). An experienced principal investigator (SK)conducted audio-recorded interviews lasting approximately 30 minutes. Researcher probed for more information where necessary and clarified the questions to obtain relevant information. Data Analysis The interviews were audio-recorded, and field notes taken. To ensure privacy, unique identification codes were assigned to each interview. The recorder used during the in-depth interviews and the transcripts were kept in a lockable cabinet accessed only by the researcher. Data were analyzed using thematic analysis. The coding framework was both deductive, where we identified quotations related to the study objective and the Three Delays’ theoretical framework, and inductive, reflective of pertinent issues raised by the data alone[ 12 ].The next step was examining coded and collated data extracts to look for potential themes of broader significance. The NVivo software version 12 was used in generating codes from the data and organizing these codes into various themes. Ethical Consideration Participants were enrolled in the study after the protocol was approved by the College of Medicine Research and Ethics Committee (COMREC Number: P.12/22/3928). Principal investigator obtained institutional approval to conduct the study at Ndirande, Zingwagwa, Bangwe, Pensulo, Lirangwe, and Madziabango Health Centres. The study followed Good Clinical Practice guidelines, and individuals were not expected to be physically harmed. Participants voluntarily signed informed consent forms before participating in the study. The interviews were done in a closed/private room that offered visual and oral privacy. Each participant provided written informed consent after reading the form. Participants had the right to withdraw or withdraw their data from the study at any stage without stating a reason. Results From the analysis, seven key themes emerged: (1) Poor communication, (2) poor road network, (3) low socioeconomic status, (4) ambulance prioritization (5) patient and guardian preferences (6) delayed treatment-seeking action, and (7) a shortage of healthcare workers. Below we synthesize the key findings according to the different levels of the three delays model include the delay in seeking care, the delay in reaching care and the delay in receiving care which informed our analytical process and supported by direct quotations from study participants. The characteristics of the patients interviewed are provided in Table 1 while those of key informants are in Table 2 . Table 1 Patients’ Social Demographic Characteristics ID Age Gender Occupation Education Catchment area P 01 46 Male Farmer Junior Certificate of Education Blantyre rural P 02 37 Male Shop clerk Malawi School Certificate of Education Blantyre rural P 03 50 Male Farmer Standard 8 Blantyre rural P 04 39 Female Primary Teacher Teaching certificate Blantyre rural P 05 30 Female Small business Form 3 Blantyre rural P 06 40 Male Farmer Standard 2 Blantyre rural P 07 32 Female Farmer Standard 8 Blantyre rural P 08 36 Male Small Business Standard 2 Blantyre rural P 09 40 Male Farmer Standard 5 Blantyre rural P 10 29 Female Farmer Standard 8 Blantyre rural P: Patient Table 2 Healthcare Workers’ Social Demographic Characteristics ID Age Gender Cadre/Occupation Education Work Experience Catchment Area CL 01 38 Female Medical Assistant Certificate in Clinical Medicine 9 Blantyre rural CL 02 30 Male Medical Assistant Certificate in Clinical Medicine 4 Blantyre rural CL 03 37 Female Clinical Technician Diploma in Clinical Medicine 15 Blantyre urban CL 04 31 Female Clinical Technician Diploma in Clinical Medicine 3 Blantyre rural CL 05 39 Female Clinical Technician Diploma in Clinical Medicine 17 Blantyre urban CL 06 31 Male Clinical Technician Diploma in Clinical Medicine 5 Blantyre urban NU 01 35 Male Nurse and Midwifery Technician Diploma in Nursing and Midwifery 12 Blantyre rural NU 02 27 Female Nurse and Midwifery Technician Diploma in Nursing and Midwifery 2 Blantyre rural NU 03 32 Male Diploma in Nursing and Midwifery Diploma in Nursing and Midwifery 8 Blantyre urban NU 04 49 Female Diploma in Nursing and Midwifery Diploma in Nursing and Midwifery 23 Blantyre rural NU 05 40 Female Diploma in Nursing and Midwifery Diploma in Nursing and Midwifery 9 Blantyre urban NU 06 32 Female Nursing Officer Bachelor of science in science in Nursing and Midwifery 7 Blantyre urban 1. CL: Clinician, 2. NU: Nurse Phase 1: The delay in seeking care Socio-economic status A few healthcare workers stated that the socioeconomic status of patients with sepsis is one of the causes of hiccups in referral pathways, especially when the patients are asked to use their transport other than when they are using an ambulance. The majority (65p%) of patients indicated that socioeconomic status directly affects the referral pathway of patients with sepsis to seek advanced care. Most participants stated that some patients were asked to use their means of transport because the Blantyre District Health Office (DHO) does not have enough ambulances to care for all patients requiring ambulance transfers. For example: “ Some patients they don’t afford to use their own transport money to seek healthcare service to advanced hospital after referral , they don’t receive it well because they have already spent maybe k2000 or k3000 from community to primary health care, so they feel overburdened to use their transport to a referral hospital ”. ( CL 02 ) However, some patients felt that asking patients to use their transport from primary health centres to referral hospitals overburdens them because they have already spent a lot of money travelling from their homes to the health centre. Circumstances of this kind delay patients from receiving sepsis treatment because, in most cases, they return home to raise money for transportation to a referral hospital. “ They gave me the referral letter, and I told them that I should first go back home and get ready in terms of transport ”. ( P 03 ) Some Health care workers expressed that patients who did not have money were delayed in being referred to the central hospital because they did not have adequate funds to sustain themselves while receiving treatment at the district hospital. Health workers spend much time convincing patients that they will find well-wishers to assist them. However, suppose the patient insists on not going to the referral hospital. In this case, they receive treatment at the primary health centre, waiting for the patient to source money for their survival at the referral hospital. “ The challenge that we face is that most patients refuse referral; they say they do not have money, how am I going to stay even if an ambulance is here, they refuse to go saying they don’t have money. We convince them you cannot lack food and the like if you go there. Some well-wishers are going to help you”. (CL 01 ) Patient and Guardian Preference A few healthcare workers said that patients and their guardians delayed the referral. When an ambulance is unavailable, guardians and patients are asked to find their means of transport to get to a referral hospital; therefore, some guardians would prefer to go home first before going to the referral hospital, so they stay longer at home. ‘’Sometimes the guardians themselves tell us to release them to go home. They complain that they have other duties and have left children at home. We see it as a challenge because the patient might be very sick, but they prefer to go home first than minding about the health of the patients, so it’s a challenge. This is so because when they go home, they delay very much such that when they go to QECH, it is difficult to document time, it might seem as if you have referred themed late yet it’s them who have delayed”. ( CL 01 ) Some participants in hard-to-reach communities reported that it is difficult for them to follow the referral pathway due to the distance and geographical position. They prefer to be referred to the closest health care centres of their choice which is not feasible at times. This has an impact on monitoring the patients and if they are going to follow through with the treatment ‘The closest hospital to my home is Chikhwawa Hospital, not Queen Elizabeth Central Hospital. So, can you just help me, like write me a referred to Chikhwawa?”. (CL 02) Delay treatment-seeking action About half (54%) of the interviewees reported that treatment-seeking behaviour contributed to a delay in referring patients to tertiary hospitals. For instance, patients opted to buy medicines from a drugstore to self-medicate or use herbs before seeking medical treatment at a referral hospital in a primary health facility. “I took bwamoto herbs and the blue gum leaves, mixed them, and took the mixture. After that, it never worked out; that’s when people hired a motorbike to take me to the clinic”. (P 05) Persistent symptoms made study participants seek medical care at a primary healthcare/health centre, where they tested negative for malaria, which made the health workers(HCW) refer the patient to QECH for further investigation and management. Most participants stated that the other pattern used before seeking medical treatment was a religious belief that before going to the health facility to seek medical treatment, people took them somewhere for prayers. Still, the persistence of the symptoms made them visit the primary hospital to seek medical care. “ So when they came, they prayed for me, and after prayer, a motorbike from my relative came to pick me up. We all rode on that motorbike (name of the health centre), and when we got there, I fainted. After that, they started finding means of transport for us to come here”. (P 02) After the tests were conducted at the primary hospital, the patient was referred to the Queen Elizabeth Central Hospital (QECH) because sepsis was suspected. Phase 2: The delay in reaching care Ambulance Prioritisation Most patients felt ambulances were prioritised for maternal and obstetric patients rather than the Out-Patient Department (OPD). When a gynecology’s and obstetrics emergency patient needs to be referred, a health worker (HCW)calls for an ambulance, as usual. An ambulance comes to pick up that patient, and if the outpatient department (OPD) suspects sepsis, the patient has access to the ambulance. According to the findings of this study, an ambulance was not sent for suspected sepsis. However, it is sent in the case of an obstetric case/patient. “Let us say you have an OPD that needs a referral; you will be lucky if an ambulance comes, but not that it was sent for that OPD. Even if you tell them that the patient has fainted, they don’t send an ambulance’’. (CL 04 ) “If we happen to have a patient from maternity and at the same time there is a patient from OPD, they use the same transport”. (NU 02 ) ‘’If you mention that it’s maternal, then it comes, but not with OPD”. ( NU 04 ) A few (5%) of the health care workers (HCW) mentioned instances where a nurse had to lie that they had a maternal condition patient from maternity for an ambulance to come. ‘’It happens (to lie) they shout at us, the driver shouts, and we tell them, the patient has given birth already, and so you can just pick this one, so they pick the patient”. ( NU 04 ) Poor Road network All healthcare (100%) mentioned that an ambulance did not go to a particular health centre during the rainy season because of poor road networks. Most of the patients cited that when roads get muddy, the ambulance does not reach the facility; and it stops at one point, so the patient with maternal sepsis should walk about 8 km to get to where the ambulance stops. ‘’ During the rainy season, the ambulance doesn’t come here because of the road's poor condition, so it stops at Manyowe, and our patients walk from here to get to where the ambulance is’’. (CL 04 ) “Our roads are in poor condition, and most cross rivers without bridges, rendering them impassable during the rainy season”. (P 04) One participant stated that if the patient with suspected maternal sepsis was seriously sick and had no means of transport, the patient was carried on a stretcher to get to where the ambulance was. ‘’ They are carried on the stretcher up there”. ( NU 03 ) Phase 3: The delay in receiving care Communication Most healthcare workers (53%) indicated that communication between healthcare workers and transport officers contributed to delayed referrals of suspected patients with sepsis. Some health care workers stated that when a patient is present at a centre, it is managed at the health centre. Healthcare workers, through the flying squad group, call a transport officer to send an ambulance for a suspected patient with sepsis to be referred. This study found that ambulances were not sent immediately. Sometimes, it takes several hours for healthcare workers to be told that ambulances are not coming, delaying the referral of patients with suspected sepsis. ‘’Sometimes they even call you to say tell them to find their means of transport, an ambulance will not come, for example, last year, we had a patient whom we called for an ambulance, we were told it was coming but, at around 4 o’clock, we were told that they should find their means transport, sometimes you can refer the patient at 8 am, and the ambulance can be coming at 4 pm afternoon”. (NU 04 ) Most healthcare workers (HCW) (60%) reported receiving only occasional or no feedback from the referral hospital after patients had been referred. Interview respondents in primary healthcare stated that this was not standard practice. The referral system sometimes lacked effective reporting procedures and feedback systems, which hindered communication between the primary health facility, referral hospital and the patients with sepsis. “I have never received feedback from referral hospital after discharge from referral hospital. If I want to get feedback, I use my unit [phone credit]”. (CL 02) The only formal provision is dedicated space in a referral letter for writing feedback. Healthcare workers (HCW) explained that even when filled in, patients usually return to their homes after discharge from the referral hospital; therefore, these documents are typically lost to the system, and feedback relies on the initiative of the more proactive clinicians who follow up via phone. Shortage of healthcare workers A few healthcare workers that understaffing contributed to referral delays for patients with suspected sepsis. Sometimes, patients must wait before they are attended to because healthcare workers are on duty, and these two should attend to all departments available in that facility. ‘’Shortage of staff makes us not treat the patient well; we can say on a day, only two clinicians are assigned on duty, and there is ART that needs to be attended, a patient can faint when you are somewhere, then you rush to see that patient, so we delay the services for the patients”. (CL 01) Another factor affecting the provision of quality referral care at the primary healthcare level, leading to self-referral and bypassing primary healthcare institutions, was a shortage of competent healthcare professionals, equipment, and medications. “Shortage of staff is a problem; patients have to wait for a long time, and some conditions worsen in the waiting queue”. (P 06) Discussion This qualitative study explored barriers of referral and referral pathways and experiences of patients with sepsis from primary healthcare to tertiary hospitals. Furthermore, it explained healthcare workers’ perspectives on the barriers associated with delayed referral of patients with sepsis in primary healthcare. The study revealed that the main referral pathways for patients with sepsis include community-to-facility referral and facility-to-facility referral. The main mode of transport includes ambulances and personal vehicles. Referral from facility to facility /hospital has improved health outcomes for several sepsis patients, such as a reduction in time of recovery and mortality rate. Despite the above strengths, facility to facility referral model presents some challenges. Reflecting on the 3-delays model as the main theoretical framework, this study identified several barriers to the functionality of the sepsis referral system in Malawi: lack of referral transport, poor communication, poor road network, shortage of skilled healthcare workers, patient preferences, and delayed treatment-seeking action. Lack of appropriate transport for sepsis cases was identified as a major challenge by all the respondents for the study. This, however, falls out of the requisites for a successful sepsis referral system from primary health care. Most patients with sepsis use personal transport and taxis as common referral transport. In low-income countries, ambulances remain scarce but possess key benefits in clinical settings. This was also found in South Africa[ 13 ] and rural Sierra Leone[ 14 ], where the most frequent mode of transport was ambulances, followed by taxis. The use of ambulances helps to ensure continuity of care during the transit period by nurses and guards against delays in travelling. Poor communication negatively affects the smooth provision of referrals and compromised the advanced care of patients with sepsis at tertiary hospitals. In this case, medical referral system functionality deteriorates patients with sepsis in need of specialist and advance care are not appropriately referred in a timely way and with accurate information, adversely impacting quality, efficiency and safety of care. This study also identified the issue of not receiving feedback from the receiving institution, which could cause referral facilities to repeat errors. The findings are consistent with those of previous African studies [ 8 , 9 , 15 , 16 ], which found poor communication between the referring and receiving facilities before and after patient transfer. Likewise, a study in Ethiopia [ 17 ], noticed that it was common to see no referral or feedback letters in low-resource countries. Wanjau et al [ 18 ], reported that good communication during the referral process can help improve the quality of referral healthcare services, including the healthcare of sepsis patients. Another major issue affecting sepsis patients to receive advance care is poor referral coordination between sending and receiving facilities reported by respondents is the scarcity of adequately equipped ambulances in primary healthcare and limited fuel for transporting patients to higher levels. The deployment of an electronic referral system, which has been extensively examined, is a key component influencing referral systems. This also explains why sepsis patients are delayed in seeking medical care at advanced hospitals leading to prolonged recovery and high mortality rates. The computerised referral system in healthcare has been shown to strengthen the link between first-level and specialised care and reduce waiting times [ 19 ]. Long distances to health centres and poor roads were important factors raised in this study and elsewhere. The situation worsens during the rainy season, and there is a prolonged delay in referring patients with suspected sepsis to advanced hospitals for timely healthcare. The study findings are aligned with the “Three delays theoretical framework”, which argues that accessibility is the functional relationship between the population and medical facilities and resources and which reflects the differential existence either of obstacles, impediments and difficulties or of factors that are facilitators for the beneficiaries of healthcare [ 11 ]. The study found that bad roads were one of the factors that worsened transport problems for patient referrals, leading to unnecessary complications and deaths. Similar findings were reported by Afari et al[ 20 ] , who noted that available ambulances could not reach most areas because the roads were not tarred. Vehicles were designed for use only on tarred roads. Studies have shown that poor road networks cause hiccups in referral pathways, especially when the patients are asked to use their transport rather than when they are using an ambulance. This study demonstrated that a good road network facilitates a smooth referral process to improve and prevent deaths occurring due to road network problems. The study also identified that understaffing contributes to referral delays for patients with suspected sepsis, as most patients experience a long waiting time before attending and eventually make a decision for referral for advance care, thereby leading to unnecessary complications and deaths. This finding was consistent with studies in Malawi[ 16 ] and Uganda[ 21 ] which also reported a shortage of well-trained personnel and diagnostic equipment as barriers to seeking care from primary-level facilities to referral hospitals. Studies further reveal that patients are affected by the provision of quality referral care at the primary healthcare level, which leads to self-referral and bypassing of primary healthcare facilities because of a shortage of skilled healthcare workers, equipment, and drugs. A study conducted in Botswana[ 22 ] noted that to address the scarcity of healthcare workers, the country should train adequate healthcare workers and distribute them equally sufficiently resourced healthcare facilities. The findings of the current study are also consistent with previous studies showing that the social position of the sufferer delays formal treatment seeking at referral hospitals. Our study revealed that patients opted to buy medicines from drugstores to self-medicate or use herbs before seeking medical treatment and at referral hospitals from primary health facilities. The study also found that patients’ religious beliefs influenced late presentation at a referral hospital before seeking treatment care at the hospital. A study by Lau et al.[ 23 ] found that among the subset of 3350 individuals who received TB screening in 51 communities, 889 (26.5%) were symptom-positive and required referral to the advanced health unit, but only 24.1% of those who received referrals successfully attended healthcare at a secondary hospital. A well-functioning referral system may serve as a motivator for primary healthcare workers by ensuring a continuum of care for sepsis patients, hence improving primary healthcare workers’ relationships with referral hospitals. Furthermore, the referral process can improve primary healthcare professionals' skills and knowledge by helping them grasp their patients’ diagnoses and treatment when they return to the community. In complex and adaptive health systems, strong and ongoing links and exchanges between patients and healthcare personnel can increase referrals, strengthen the health system, and contribute to better health outcomes. Study strengths and limitations. This study provides information on the referral of sepsis patients from primary health care to a tertiary health facility in Malawi. In Malawi where there is little research on the referral process and other obstacles faced when receiving care at tertiary health facilities, the study adds to the body of information regarding sepsis referrals to tertiary hospitals. The cross-sectional nature of the study did not capture changes over time but captured experiences and perceptions in a specific context. The translated participants’ quotes from Chichewa to English might have lost the original meaning. Another limitation is that, as with any qualitative research, this study had a limited sample of respondents and, therefore, cannot represent all challenges of the referral system in primary healthcare in Malawi but may portray a picture of what is happening in primary healthcare with similar characteristics. Conclusion A significant component of sepsis-related deaths in developing countries, including Malawi, is attributable to referral systems confronted with multiple barriers in the care delivery process. Therefore, it is necessary to investigate the high-impact bundling strategies focusing on these bottlenecks. From the findings of this study, it was concluded that the referral system in Blantyre District needs to be adequately resourced to provide quality primary referral healthcare services. This is reflected in the factors identified in the interviews. It was concluded that patients’ delays and failure to access prompt and timely referral services were mainly due to the system’s lack of transportation, communication problems, bad road networks, and shortage of healthcare workers. It was also noted that the services at the referral facility were of low quality owing to the high number of self-referrals, which was attributed to drug stock outs, lack of diagnostic equipment, and providers’ skills at the primary level of healthcare. Multilevel interventions are required to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of building more functional systems to optimise the continuum and quality of sepsis care for rural populations in similar settings. Abbreviations BDHO Blantyre District Health Office COMREC College of Medicine Research and Ethics Committee DHO District Health Office HCW Health care worker LMICS Low Middle Income Countries OPD Outpatient Department PHC Primary Health care QECH Queen Elizabeth Central Hospital Declarations Consent for publication: Not Applicable Competing Interest: The author declares they have no personal interest Clinical trial number: Not applicable. Funding: The study was self-funded by the first author. Author Contribution S. K. did data collection , data analysis and writing main manuscriptE.U. Review manuscript Acknowledgements We would like to thank all the study participants for their help. Availability of data and materials. The dataset used and or analysed during this study is available from the corresponding author on rational request. References Singer M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). 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Surg (United States). 2016;160:1636–44. Kea AZ, Tulloch O, Datiko DG, et al. Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia. BMC Pregnancy Childbirth. 2018;18:1–12. Ayodo DKNWBWME. Factors Affecting Provision of Service Quality in the Public Health Sector: A Case of Kenyatta National Hospital. Int J Humanit Soc Sci. 2012;2:114–25. Chowdhury S, Chakraborty Ppratim. Universal health coverage – There is more to it than meets the eye. J Fam Med Prim Care. 2017;6:169–70. Afari H, Hirschhorn LR, Michaelis A et al. Quality improvement in emergency obstetric referrals: Qualitative study of provider perspectives in Assin North district, Ghana. BMJ Open ; 4. Epub ahead of print 2014. 10.1136/bmjopen-2014-005052 Sami S, Amsalu R, Dimiti A, et al. Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: A mixed methods case study. BMC Pregnancy Childbirth. 2018;18:1–12. Nkomazana O, Mash R, Shaibu S, et al. Stakeholders’ perceptions on shortage of healthcare workers in primary healthcare in Botswana: Focus group discussions. PLoS ONE. 2015;10:1–15. Lau LLH, Hung N, Dodd W, et al. Social trust and health seeking behaviours: A longitudinal study of a community-based active tuberculosis case finding program in the Philippines. SSM - Popul Heal. 2020;12:100664. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Jan, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 30 Sep, 2024 Editor assigned by journal 25 Sep, 2024 Submission checks completed at journal 25 Sep, 2024 First submitted to journal 23 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5136636","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":360563481,"identity":"3a550434-02af-4ab8-a256-27512740b67e","order_by":0,"name":"Sylvester Kaimba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYDACdhiDB4gZGxjkQOwDD/BpYQaTBnAtxmAtCaRoSWwA8fFpkW/mMZP48OePnHnP4YePbu6wS58fdvgh0BY7Od0G7FoMDvOYSc5sMzCWOdtmbJx7Jjl34+00A6CWZGOzAzi0MPMYG/M2GCTO4Gcwk85tY87dODsBpOVA4jYcWoAOMzb+88egfgY/+zeglvp0w9npH/BqYTjMY/iYgc0gQYK3B2TL4QR56Rz8thgcZit82NtmbDiD50wx0C/HDTdI5xQcSDDA7Rf59uYNB378kZOX4Enf+Dh3R7W8/Oz0zR8+VNjJ4dLCwMBhgGYvWKUBFpVwwP4Azd4GfKpHwSgYBaNgJAIAEE9esgWR/PwAAAAASUVORK5CYII=","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sylvester","middleName":"","lastName":"Kaimba","suffix":""},{"id":360563483,"identity":"3f0460ae-1468-42e6-9f27-0afe214da054","order_by":1,"name":"Eric umar","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eric","middleName":"","lastName":"umar","suffix":""}],"badges":[],"createdAt":"2024-09-23 08:56:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5136636/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5136636/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-02708-1","type":"published","date":"2025-01-18T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":74284605,"identity":"dc6bde29-f7e3-47cc-a9f2-11a3a4e84183","added_by":"auto","created_at":"2025-01-20 16:09:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":778754,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5136636/v1/ee801593-d57a-485d-b382-cd3c953783fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Associated with Delayed Referrals of Patients with Sepsis from Primary to Tertiary Healthcare in Blantyre, Malawi: A Qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eSepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, is a significant global health concern[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its related deaths account for 19.7% of all global deaths annually [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Most of the worldwide burden of sepsis occurs in low- and middle-income countries (LMICs), where nearly 85% of an estimated 48.9\u0026nbsp;million annual cases of sepsis occur (WHO 2020 In 2017, sepsis incidence and mortality varied substantially across regions, with the highest burden in Africa, Oceania, south Asia, east Asia, and southeast Asia[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Itis a life-threatening illness that requires prompt identification and early definitive medical intervention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSepsis is likely under-recognised in African countries due to limited diagnostic competence, varied reporting, and a lack of universal death registers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In high-income settings, outcomes are improving because of the comprehensive application of an expanding evidence base for early recognition, rapid administration of appropriate antimicrobials, and aggressive fluid resuscitation, paired with intensive physiology monitoring and organ support provision [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Malawi's intensive care units are responsible for 40% of the mortality [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In Malawi, severe cases of sepsis are referred to tertiary health facilities for specialist care. However, sepsis cases are frequently diagnosed too late, resulting in a high sepsis-related in-hospital mortality of between 17 and 50 percent [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This study sheds light on the barriers to timely referral of patients with sepsis and lessons to prevent referral delays to improve patient outcomes.\u003c/p\u003e\n\u003ch3\u003eTheoretical frameworks\u003c/h3\u003e\n\u003cp\u003eThis study categorised the collected data using the adopted “Three Delays’ theoretical framework[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The Three Delays Model has been widely applied to understand maternal mortality but it has not been systematically applied to the context of medical conditions more broadly. This model could serve as a useful framework for establishing factors associated with delay referral of medical conditions including sepsis to one level of care to another referral hospital. The study discovered that the three delays described by Thaddeus and Maine (1994) were delays in seeking, reaching, and receiving care[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n\n\n "},{"header":"METHODS","content":"\u003ch2\u003eResearch Design\u003c/h2\u003e\u003cp\u003eThis cross-sectional qualitative descriptive study comprised in-person in-depth interviews (IDIs) with two participant groups: patients recovering from sepsis and healthcare workers (HCWs). This study was conducted at six Blantyre District Health Office (DHO) health centres selected randomly, namely, Madziabango, Pesulu, Lirangwe, Bangwe, Ndirande, and Zingwagwa health centres.\u003c/p\u003e\u003ch3\u003eSampling procedure\u003c/h3\u003e\u003cp\u003eA total of 22 participants were purposively sampled and interviewed. The final sample size was determined through saturation; thus, until the information collected from each subsequent interview was repeated [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A simple random sampling method (casting of lots) was used to select three urban and three rural primary healthcare centres from the Blantyre District Health Office (DHO) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Inclusion criteria were adult patients referred from the health centre to Queens Elizabeth central hospital (QECH)with sepsis and discharge and recovering at home and Health care workers providing direct and indirect care of patients with sepsis.\u003c/p\u003e\u003ch3\u003eData Collection\u003c/h3\u003e\u003cp\u003eData were collected using a semi-structured interview topic guide containing questions that elicited free responses. After obtaining written consent, patient interviews were conducted in the local language (Chichewa), whereas interviews with HCWs were conducted in English or Chichewa, depending on the interviewee’s preference. The interviews were conducted in a private room within the health facility. The interviews were conducted between 1 May 2023 and 16 May 2023, with ten patients (6 males and 4 females) and 12 HCWs (9 females and 3 males). An experienced principal investigator (SK)conducted audio-recorded interviews lasting approximately 30 minutes. Researcher probed for more information where necessary and clarified the questions to obtain relevant information.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe interviews were audio-recorded, and field notes taken. To ensure privacy, unique identification codes were assigned to each interview. The recorder used during the in-depth interviews and the transcripts were kept in a lockable cabinet accessed only by the researcher. Data were analyzed using thematic analysis. The coding framework was both deductive, where we identified quotations related to the study objective and the Three Delays’ theoretical framework, and inductive, reflective of pertinent issues raised by the data alone[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].The next step was examining coded and collated data extracts to look for potential themes of broader significance. The NVivo software version 12 was used in generating codes from the data and organizing these codes into various themes.\u003c/p\u003e\u003ch2\u003eEthical Consideration\u003c/h2\u003e\u003cp\u003eParticipants were enrolled in the study after the protocol was approved by the College of Medicine Research and Ethics Committee (COMREC Number: P.12/22/3928). Principal investigator obtained institutional approval to conduct the study at Ndirande, Zingwagwa, Bangwe, Pensulo, Lirangwe, and Madziabango Health Centres. The study followed Good Clinical Practice guidelines, and individuals were not expected to be physically harmed. Participants voluntarily signed informed consent forms before participating in the study. The interviews were done in a closed/private room that offered visual and oral privacy. Each participant provided written informed consent after reading the form. Participants had the right to withdraw or withdraw their data from the study at any stage without stating a reason.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom the analysis, seven key themes emerged: (1) Poor communication, (2) poor road network, (3) low socioeconomic status, (4) ambulance prioritization (5) patient and guardian preferences (6) delayed treatment-seeking action, and (7) a shortage of healthcare workers. Below we synthesize the key findings according to the different levels of the three delays model include the delay in seeking care, the delay in reaching care and the delay in receiving care which informed our analytical process and supported by direct quotations from study participants. The characteristics of the patients interviewed are provided in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e while those of key informants are in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; Social Demographic Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCatchment area\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJunior Certificate of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShop clerk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMalawi School Certificate of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Teacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTeaching certificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSmall business\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eForm 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSmall Business\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eP: Patient\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealthcare Workers\u0026rsquo; Social Demographic Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCadre/Occupation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWork Experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCatchment Area\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL 01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedical Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCertificate in Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL 02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedical Assistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCertificate in Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL 03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL 04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL 05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL 06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNU 01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurse and Midwifery Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNU 02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurse and Midwifery Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNU 03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNU 04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNU 05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiploma in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNU 06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNursing Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor of science in science in Nursing and Midwifery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBlantyre urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1. CL: Clinician, 2. NU: Nurse\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003ePhase 1: The delay in seeking care\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section4\"\u003e \u003ch2\u003eSocio-economic status\u003c/h2\u003e \u003cp\u003eA few healthcare workers stated that the socioeconomic status of patients with sepsis is one of the causes of hiccups in referral pathways, especially when the patients are asked to use their transport other than when they are using an ambulance. The majority (65p%) of patients indicated that socioeconomic status directly affects the referral pathway of patients with sepsis to seek advanced care. Most participants stated that some patients were asked to use their means of transport because the Blantyre District Health Office (DHO) does not have enough ambulances to care for all patients requiring ambulance transfers. For example:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003e\u0026ldquo;\u003c/b\u003e \u003cem\u003eSome patients they don\u0026rsquo;t afford to use their own transport money to seek healthcare service to advanced hospital after referral\u003c/em\u003e, \u003cem\u003ethey don\u0026rsquo;t receive it well because they have already spent maybe k2000 or k3000 from community to primary health care, so they feel overburdened to use their transport to a referral hospital\u003c/em\u003e\u0026rdquo;. \u003cem\u003e(\u003c/em\u003eCL 02\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some patients felt that asking patients to use their transport from primary health centres to referral hospitals overburdens them because they have already spent a lot of money travelling from their homes to the health centre. Circumstances of this kind delay patients from receiving sepsis treatment because, in most cases, they return home to raise money for transportation to a referral hospital.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThey gave me the referral letter, and I told them that I should first go back home and get ready in terms of transport\u003c/em\u003e\u0026rdquo;. (\u003cem\u003eP 03\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome Health care workers expressed that patients who did not have money were delayed in being referred to the central hospital because they did not have adequate funds to sustain themselves while receiving treatment at the district hospital. Health workers spend much time convincing patients that they will find well-wishers to assist them. However, suppose the patient insists on not going to the referral hospital. In this case, they receive treatment at the primary health centre, waiting for the patient to source money for their survival at the referral hospital.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe challenge that we face is that most patients refuse referral; they say they do not have money, how am I going to stay even if an ambulance is here, they refuse to go saying they don\u0026rsquo;t have money. We convince them you cannot lack food and the like if you go there. Some well-wishers are going to help you\u0026rdquo;. (CL 01\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePatient and Guardian Preference\u003c/h2\u003e \u003cp\u003eA few healthcare workers said that patients and their guardians delayed the referral. When an ambulance is unavailable, guardians and patients are asked to find their means of transport to get to a referral hospital; therefore, some guardians would prefer to go home first before going to the referral hospital, so they stay longer at home.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;Sometimes the guardians themselves tell us to release them to go home. They complain that they have other duties and have left children at home. We see it as a challenge because the patient might be very sick, but they prefer to go home first than minding about the health of the patients, so it\u0026rsquo;s a challenge. This is so because when they go home, they delay very much such that when they go to QECH, it is difficult to document time, it might seem as if you have referred themed late yet it\u0026rsquo;s them who have delayed\u0026rdquo;. (\u003c/em\u003eCL 01\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome participants in hard-to-reach communities reported that it is difficult for them to follow the referral pathway due to the distance and geographical position. They prefer to be referred to the closest health care centres of their choice which is not feasible at times. This has an impact on monitoring the patients and if they are going to follow through with the treatment\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;The closest hospital to my home is Chikhwawa Hospital, not Queen Elizabeth Central Hospital. So, can you just help me, like write me a referred to Chikhwawa?\u0026rdquo;. (CL 02)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDelay treatment-seeking action\u003c/h2\u003e \u003cp\u003eAbout half (54%) of the interviewees reported that treatment-seeking behaviour contributed to a delay in referring patients to tertiary hospitals. For instance, patients opted to buy medicines from a drugstore to self-medicate or use herbs before seeking medical treatment at a referral hospital in a primary health facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I took bwamoto herbs and the blue gum leaves, mixed them, and took the mixture. After that, it never worked out; that\u0026rsquo;s when people hired a motorbike to take me to the clinic\u0026rdquo;. (P 05)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePersistent symptoms made study participants seek medical care at a primary healthcare/health centre, where they tested negative for malaria, which made the health workers(HCW) refer the patient to QECH for further investigation and management.\u003c/p\u003e \u003cp\u003eMost participants stated that the other pattern used before seeking medical treatment was a religious belief that before going to the health facility to seek medical treatment, people took them somewhere for prayers. Still, the persistence of the symptoms made them visit the primary hospital to seek medical care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSo when they came, they prayed for me, and after prayer, a motorbike from my relative came to pick me up. We all rode on that motorbike (name of the health centre), and when we got there, I fainted. After that, they started finding means of transport for us to come here\u0026rdquo;. (P 02)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAfter the tests were conducted at the primary hospital, the patient was referred to the Queen\u003c/p\u003e \u003cp\u003eElizabeth Central Hospital (QECH) because sepsis was suspected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2: The delay in reaching care\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eAmbulance Prioritisation\u003c/h2\u003e \u003cp\u003eMost patients felt ambulances were prioritised for maternal and obstetric patients rather than the Out-Patient Department (OPD). When a gynecology\u0026rsquo;s and obstetrics emergency patient needs to be referred, a health worker (HCW)calls for an ambulance, as usual. An ambulance comes to pick up that patient, and if the outpatient department (OPD) suspects sepsis, the patient has access to the ambulance. According to the findings of this study, an ambulance was not sent for suspected sepsis. However, it is sent in the case of an obstetric case/patient.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Let us say you have an OPD that needs a referral; you will be lucky if an ambulance comes, but not that it was sent for that OPD. Even if you tell them that the patient has fainted, they don\u0026rsquo;t send an ambulance\u0026rsquo;\u0026rsquo;. (CL\u003c/em\u003e 04\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If we happen to have a patient from maternity and at the same time there is a patient from OPD, they use the same transport\u0026rdquo;. (NU\u003c/em\u003e 02\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;If you mention that it\u0026rsquo;s maternal, then it comes, but not with OPD\u0026rdquo;. (\u003c/em\u003eNU 04\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few (5%) of the health care workers (HCW) mentioned instances where a nurse had to lie that they had a maternal condition patient from maternity for an ambulance to come.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;It happens (to lie) they shout at us, the driver shouts, and we tell them, the patient has given birth already, and so you can just pick this one, so they pick the patient\u0026rdquo;. (\u003c/em\u003eNU 04\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePoor Road network\u003c/h2\u003e \u003cp\u003eAll healthcare (100%) mentioned that an ambulance did not go to a particular health centre during the rainy season because of poor road networks. Most of the patients cited that when roads get muddy, the ambulance does not reach the facility; and it stops at one point, so the patient with maternal sepsis should walk about 8 km to get to where the ambulance stops.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;\u0026rsquo;\u003cem\u003eDuring the rainy season, the ambulance doesn\u0026rsquo;t come here because of the road's poor condition, so it stops at Manyowe, and our patients walk from here to get to where the ambulance is\u0026rsquo;\u0026rsquo;. (CL\u003c/em\u003e 04\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Our roads are in poor condition, and most cross rivers without bridges, rendering them impassable during the rainy season\u0026rdquo;. (P 04)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant stated that if the patient with suspected maternal sepsis was seriously sick and had no means of transport, the patient was carried on a stretcher to get to where the ambulance was.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo; They are carried on the stretcher up there\u0026rdquo;. (\u003c/em\u003eNU 03\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePhase 3: The delay in receiving care\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eCommunication\u003c/h2\u003e \u003cp\u003eMost healthcare workers (53%) indicated that communication between healthcare workers and transport officers contributed to delayed referrals of suspected patients with sepsis. Some health care workers stated that when a patient is present at a centre, it is managed at the health centre. Healthcare workers, through the flying squad group, call a transport officer to send an ambulance for a suspected patient with sepsis to be referred. This study found that ambulances were not sent immediately. Sometimes, it takes several hours for healthcare workers to be told that ambulances are not coming, delaying the referral of patients with suspected sepsis.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;Sometimes they even call you to say tell them to find their means of transport, an ambulance will not come, for example, last year, we had a patient whom we called for an ambulance, we were told it was coming but, at around 4 o\u0026rsquo;clock, we were told that they should find their means transport, sometimes you can refer the patient at 8 am, and the ambulance can be coming at 4 pm afternoon\u0026rdquo;.\u003c/em\u003e (NU 04\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMost healthcare workers (HCW) (60%) reported receiving only occasional or no feedback from the referral hospital after patients had been referred. Interview respondents in primary healthcare stated that this was not standard practice. The referral system sometimes lacked effective reporting procedures and feedback systems, which hindered communication between the primary health facility, referral hospital and the patients with sepsis.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have never received feedback from referral hospital after discharge from referral hospital. If I want to get feedback, I use my unit [phone credit]\u0026rdquo;. (CL 02)\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThe only formal provision is dedicated space in a referral letter for writing feedback. Healthcare workers (HCW) explained that even when filled in, patients usually return to their homes after discharge from the referral hospital; therefore, these documents are typically lost to the system, and feedback relies on the initiative of the more proactive clinicians who follow up via phone.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eShortage of healthcare workers\u003c/h2\u003e \u003cp\u003eA few healthcare workers that understaffing contributed to referral delays for patients with suspected sepsis. Sometimes, patients must wait before they are attended to because healthcare workers are on duty, and these two should attend to all departments available in that facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;Shortage of staff makes us not treat the patient well; we can say on a day, only two clinicians are assigned on duty, and there is ART that needs to be attended, a patient can faint when you are somewhere, then you rush to see that patient, so we delay the services for the patients\u0026rdquo;. (CL 01)\u003c/em\u003e \u003c/p\u003e\u003cp\u003eAnother factor affecting the provision of quality referral care at the primary healthcare level, leading to self-referral and bypassing primary healthcare institutions, was a shortage of competent healthcare professionals, equipment, and medications.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Shortage of staff is a problem; patients have to wait for a long time, and some conditions worsen in the waiting queue\u0026rdquo;. (P 06)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study explored barriers of referral and referral pathways and experiences of patients with sepsis from primary healthcare to tertiary hospitals. Furthermore, it explained healthcare workers\u0026rsquo; perspectives on the barriers associated with delayed referral of patients with sepsis in primary healthcare. The study revealed that the main referral pathways for patients with sepsis include community-to-facility referral and facility-to-facility referral. The main mode of transport includes ambulances and personal vehicles. Referral from facility to facility /hospital has improved health outcomes for several sepsis patients, such as a reduction in time of recovery and mortality rate. Despite the above strengths, facility to facility referral model presents some challenges. Reflecting on the 3-delays model as the main theoretical framework, this study identified several barriers to the functionality of the sepsis referral system in Malawi: lack of referral transport, poor communication, poor road network, shortage of skilled healthcare workers, patient preferences, and delayed treatment-seeking action.\u003c/p\u003e \u003cp\u003eLack of appropriate transport for sepsis cases was identified as a major challenge by all the respondents for the study. This, however, falls out of the requisites for a successful sepsis referral system from primary health care. Most patients with sepsis use personal transport and taxis as common referral transport. In low-income countries, ambulances remain scarce but possess key benefits in clinical settings. This was also found in South Africa[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and rural Sierra Leone[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], where the most frequent mode of transport was ambulances, followed by taxis. The use of ambulances helps to ensure continuity of care during the transit period by nurses and guards against delays in travelling.\u003c/p\u003e \u003cp\u003ePoor communication negatively affects the smooth provision of referrals and compromised the advanced care of patients with sepsis at tertiary hospitals. In this case, medical referral system functionality deteriorates patients with sepsis in need of specialist and advance care are not appropriately referred in a timely way and with accurate information, adversely impacting quality, efficiency and safety of care. This study also identified the issue of not receiving feedback from the receiving institution, which could cause referral facilities to repeat errors. The findings are consistent with those of previous African studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which found poor communication between the referring and receiving facilities before and after patient transfer. Likewise, a study in Ethiopia [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], noticed that it was common to see no referral or feedback letters in low-resource countries. Wanjau et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], reported that good communication during the referral process can help improve the quality of referral healthcare services, including the healthcare of sepsis patients. Another major issue affecting sepsis patients to receive advance care is poor referral coordination between sending and receiving facilities reported by respondents is the scarcity of adequately equipped ambulances in primary healthcare and limited fuel for transporting patients to higher levels. The deployment of an electronic referral system, which has been extensively examined, is a key component influencing referral systems. This also explains why sepsis patients are delayed in seeking medical care at advanced hospitals leading to prolonged recovery and high mortality rates. The computerised referral system in healthcare has been shown to strengthen the link between first-level and specialised care and reduce waiting times [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Long distances to health centres and poor roads were important factors raised in this study and elsewhere. The situation worsens during the rainy season, and there is a prolonged delay in referring patients with suspected sepsis to advanced hospitals for timely healthcare.\u003c/p\u003e \u003cp\u003eThe study findings are aligned with the \u0026ldquo;Three delays theoretical framework\u0026rdquo;, which argues that accessibility is the functional relationship between the population and medical facilities and resources and which reflects the differential existence either of obstacles, impediments and difficulties or of factors that are facilitators for the beneficiaries of healthcare [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The study found that bad roads were one of the factors that worsened transport problems for patient referrals, leading to unnecessary complications and deaths. Similar findings were reported by Afari et al[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e, who noted that available ambulances could not reach most areas because the roads were not tarred. Vehicles were designed for use only on tarred roads. Studies have shown that poor road networks cause hiccups in referral pathways, especially when the patients are asked to use their transport rather than when they are using an ambulance. This study demonstrated that a good road network facilitates a smooth referral process to improve and prevent deaths occurring due to road network problems.\u003c/p\u003e \u003cp\u003eThe study also identified that understaffing contributes to referral delays for patients with suspected sepsis, as most patients experience a long waiting time before attending and eventually make a decision for referral for advance care, thereby leading to unnecessary complications and deaths. This finding was consistent with studies in Malawi[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and Uganda[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] which also reported a shortage of well-trained personnel and diagnostic equipment as barriers to seeking care from primary-level facilities to referral hospitals. Studies further reveal that patients are affected by the provision of quality referral care at the primary healthcare level, which leads to self-referral and bypassing of primary healthcare facilities because of a shortage of skilled healthcare workers, equipment, and drugs. A study conducted in Botswana[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] noted that to address the scarcity of healthcare workers, the country should train adequate healthcare workers and distribute them equally sufficiently resourced healthcare facilities.\u003c/p\u003e \u003cp\u003eThe findings of the current study are also consistent with previous studies showing that the social position of the sufferer delays formal treatment seeking at referral hospitals. Our study revealed that patients opted to buy medicines from drugstores to self-medicate or use herbs before seeking medical treatment and at referral hospitals from primary health facilities. The study also found that patients\u0026rsquo; religious beliefs influenced late presentation at a referral hospital before seeking treatment care at the hospital. A study by Lau et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] found that among the subset of 3350 individuals who received TB screening in 51 communities, 889 (26.5%) were symptom-positive and required referral to the advanced health unit, but only 24.1% of those who received referrals successfully attended healthcare at a secondary hospital.\u003c/p\u003e \u003cp\u003eA well-functioning referral system may serve as a motivator for primary healthcare workers by ensuring a continuum of care for sepsis patients, hence improving primary healthcare workers\u0026rsquo; relationships with referral hospitals. Furthermore, the referral process can improve primary healthcare professionals' skills and knowledge by helping them grasp their patients\u0026rsquo; diagnoses and treatment when they return to the community. In complex and adaptive health systems, strong and ongoing links and exchanges between patients and healthcare personnel can increase referrals, strengthen the health system, and contribute to better health outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy strengths and limitations.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study provides information on the referral of sepsis patients from primary health care to a tertiary health facility in Malawi. In Malawi where there is little research on the referral process and other obstacles faced when receiving care at tertiary health facilities, the study adds to the body of information regarding sepsis referrals to tertiary hospitals. The cross-sectional nature of the study did not capture changes over time but captured experiences and perceptions in a specific context. The translated participants\u0026rsquo; quotes from Chichewa to English might have lost the original meaning. Another limitation is that, as with any qualitative research, this study had a limited sample of respondents and, therefore, cannot represent all challenges of the referral system in primary healthcare in Malawi but may portray a picture of what is happening in primary healthcare with similar characteristics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA significant component of sepsis-related deaths in developing countries, including Malawi, is attributable to referral systems confronted with multiple barriers in the care delivery process. Therefore, it is necessary to investigate the high-impact bundling strategies focusing on these bottlenecks. From the findings of this study, it was concluded that the referral system in Blantyre District needs to be adequately resourced to provide quality primary referral healthcare services. This is reflected in the factors identified in the interviews. It was concluded that patients\u0026rsquo; delays and failure to access prompt and timely referral services were mainly due to the system\u0026rsquo;s lack of transportation, communication problems, bad road networks, and shortage of healthcare workers. It was also noted that the services at the referral facility were of low quality owing to the high number of self-referrals, which was attributed to drug stock outs, lack of diagnostic equipment, and providers\u0026rsquo; skills at the primary level of healthcare. Multilevel interventions are required to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of building more functional systems to optimise the continuum and quality of sepsis care for rural populations in similar settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBDHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Blantyre District Health Office\u003c/p\u003e\n\u003cp\u003eCOMREC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;College of Medicine Research and Ethics Committee\u003c/p\u003e\n\u003cp\u003eDHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; District Health Office\u003c/p\u003e\n\u003cp\u003eHCW \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health care worker\u003c/p\u003e\n\u003cp\u003eLMICS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Low Middle Income Countries\u003c/p\u003e\n\u003cp\u003eOPD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Outpatient Department\u003c/p\u003e\n\u003cp\u003ePHC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Primary Health care\u003c/p\u003e\n\u003cp\u003eQECH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Queen Elizabeth Central Hospital\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting Interest:\u003c/strong\u003e \u003cp\u003eThe author declares they have no personal interest\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe study was self-funded by the first author.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS. K. did data collection , data analysis and writing main manuscriptE.U. Review manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eWe would like to thank all the study participants for their help.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials.\u003c/h2\u003e \u003cp\u003eThe dataset used and or analysed during this study is available from the corresponding author on rational request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSinger M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA - J Am Med Assoc. 2016;315:801\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwizera A, Urayeneza O, Mujyarugamba P, et al. Epidemiology and Outcome of Sepsis in Adults and Children in a Rural, Sub-Sahara African Setting. 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SSM - Popul Heal. 2020;12:100664.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sepsis, Referral pathway, Primary health care, Tertiary hospital, Delay referral","lastPublishedDoi":"10.21203/rs.3.rs-5136636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5136636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSepsis is a significant global health problem, particularly in low- and middle-income countries. Sepsis is a life-threatening condition that requires prompt identification and early definitive medical intervention. Globally, sepsis is common, with estimated 31.5\u0026nbsp;million cases per year. Sepsis accounts for a significant in-hospital mortality rate of 17% in high-income countries while in Malawi, it ranges from 17\u0026ndash;50%. For Malawi, the trend can be reversed with improvements in patient referral system within the healthcare system. The study set out to establish the referral pathway of patients with sepsis from primary healthcare to tertiary hospitals and to understand healthcare workers and patients\u0026rsquo; perspectives on barriers associated with delayed referral of patients with sepsis from primary to tertiary healthcare.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive study in six health centres within Blantyre District health office included 22 face-to-face semi-structured interviews with purposively selected patients recovering from sepsis and with healthcare workers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study revealed that the main referral pathways for patients with sepsis include community-to-facility and facility-to-facility referrals. Ambulances and personal transport are common transportation mode used during referrals. Primary care facilities face several challenges that delay referrals from primary to tertiary health facility of patients with sepsis, such as lack of referral transport, poor communication, poor road network, shortage of skilled healthcare workers, patient preferences, delayed treatment-seeking action, and ambulances prioritising maternal conditions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; delay and failure to access prompt and timely referral services result from the healthcare system\u0026rsquo;s lack of transport, communication problems, bad road networks and shortage of well-trained personnel. Referral delays have deleterious effects on patient-care outcomes.\u003c/p\u003e","manuscriptTitle":"Factors Associated with Delayed Referrals of Patients with Sepsis from Primary to Tertiary Healthcare in Blantyre, Malawi: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-18 06:56:21","doi":"10.21203/rs.3.rs-5136636/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-30T09:54:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-25T06:43:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-25T06:43:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-09-23T08:55:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e1ff0029-1ecc-4e2b-8446-0a95d0851c56","owner":[],"postedDate":"November 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:01:57+00:00","versionOfRecord":{"articleIdentity":"rs-5136636","link":"https://doi.org/10.1186/s12875-025-02708-1","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-01-18 15:57:32","publishedOnDateReadable":"January 18th, 2025"},"versionCreatedAt":"2024-11-18 06:56:21","video":"","vorDoi":"10.1186/s12875-025-02708-1","vorDoiUrl":"https://doi.org/10.1186/s12875-025-02708-1","workflowStages":[]},"version":"v1","identity":"rs-5136636","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5136636","identity":"rs-5136636","version":["v1"]},"buildId":"cTy_lsJlmDsVRNrSptgXS","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}