Does a formal referral system work? Case study of a tertiary teaching and referral hospital in Kenya: Pre-posttest study

Does a formal referral system work? 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Case study of a tertiary teaching and referral hospital in Kenya: Pre-posttest study Maxwell Philip Omondi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3962350/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low use of formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. This compromises the ability and capacity of Kenyatta National Hospital to function as a referral facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and Kenyatta National Hospital legal statue of 1987. On 1st July 2021, Kenyatta National Hospital (KNH) did enforce the national referral guidelines that required patients have a formal referral letter to reduce the number of self-referrals, decongest KNH and allow KNH to function as a referral facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 2010 constitution and KNH legal statue of 1987. The purpose of this study was to analyse the effect of enforcement of national referral guidelines on use of official facility referral letters to KNH.This was a pre-posttest study design. The study was conducted amongst the orthopedic and trauma facility referrals in 2021 with 222 and 246 before and after enforcement of referral guidelines respectively. Data collection was done through data abstraction. Data was analyzed using frequency distribution, pearson chi-square test and logistic regression. The enforcement of the national referral guidelines had no effect on the use of the official written referral letters as per the requirement of the national referral guidelines amongst the orthopedic and trauma admissions at KNH (p = 0.524). Over 80% of facility referrals were young and middle-aged patients before and after enforcement of the referral guidelines with children and elderly representing the minority. Most of the facility referrals had had primary and secondary level of education with admissions. Women, elective patients and those with higher education were more likely to have a written referral letter (p < 0.05). In conclusion, enforcement of the referral guidelines had no effect on use of the official written referral letters to KNH. There is need for capacity building of health care workers on effective referral process by designing and disseminating referral SOPs and standardized documentation for referrals and regular referral review forums to review coordination, encourage accountability and continuous improvement and referral performance monitoring. referral guidelines health facility referrals referral letters Kenyatta National Hospital Figures Figure 1 Background Referral is a mechanism to comprehensively manage clients’ health needs by using resources beyond those available where they access care. It is the process by which a given level of health services that has inadequate capacity to manage a given health condition or event seeks the assistance of a higher level of healthcare delivery to guide or take over the management of the condition. With this approach, the Kenya health sector has developed a referral strategy, standard guidelines, and forms to guide the sector in building an effective system that responds to the needs of both rural and poor populations and in the process improve equitable access to quality health services to all Kenyans in an effort to reverse the declining health indicators. In this way, the health sector can contribute towards Kenya’s realization of Vision 2030, the Millennium Development Goals, and other health-related targets ( 1 ). The Kenya Health Policy 2012–2030 has identified the need to strengthen the referral system in Kenya as a way of improving efficiency in the health system and improving patient outcomes. In the 2012–2018 Kenya Health Sector Strategic and Investment Plan (KHSSP 2012–2018), referral systems strengthening is one of the seven priority areas under investment area one of service delivery systems. Some of the critical investment priorities for the referral system outlined in the KHSSP 2012–2018 include ( 1 ) updated referral tools and guidelines at all levels ( 2 ) orientation of the management teams on their referral roles and functions ( 1 ). According to Kenya Medium Term plan 2013–2017, increasing the utilization of services at lower levels of the health services and reduce self-referral to the higher levels of care is one of the key priorities to improve access to health care ( 2 ). Kenya devolved system of government provides for one ( 1 ) national government and forty-seven ( 47 ) county governments. The Fourth Schedule of the Constitution, has assigned different functions to the two levels of government. In the devolved system, the mandate of the national-level MOH consists of provision of care and management of the national referral health facilities, formulation of health policy, development of norms, standards and guidelines, and provision of capacity building and technical assistance for the counties. The mandate of the counties includes, among others, the provision of health services and management of referrals in county health facilities and pharmacies ( 1 , 3 ). The delivery of the Kenya Essential Package for Health (KEPH) health services in Kenya is organized across six levels of care, beginning at the community level and continuing through primary care services, which include dispensaries (level 2) and health centers (level 3) and county referral health services (level 4 & 5) all the way to the national referral health services (level 6) (Fig. 1 ). The strengthening of referral linkages across service delivery units is one of the elements in the health policy strategy to achieve an efficient health service delivery system that maximizes health outcomes ( 6 , 7 ). Level 4 are primary referral health facilities; level 5 are secondary referral health facilities and level 6 are tertiary referral health facilities. These six levels of care fits into 4 tiers of care. The first tier consists of the community health units. The second tier consists of the primary health care facilities that have dispensaries, health centers and private maternity and nursing homes. The third tier consists of the county referral facilities, which include the former primary and secondary hospitals. The fourth tier, the national referral facilities that offer highly specialized care, is used for training and support research (Fig. 1 ). Health facilities in the various tiers of care include government-owned facilities, faith-based organizations, and private health institutions. ( 3 , 6 , 8 ). Some of the challenges in health referral systems in most developing countries include noncompliance with referrals ( 9 , 10 ) delays in referral completion ( 11 – 13 ) high numbers of self-referrals to higher-level referral facilities ( 11 , 14 ). This is because of lack of awareness on where to get cost-effective health services for different conditions, perception that lower levels of care provide lower quality of care for uncomplicated health conditions, the system delays referrals to the next level of care in cases when complications require an emergency intervention and lack of primary care facilities within geographical reach of the clients and the fact that the tertiary health facilities are the closest facilities ( 7 , 15 ). Many people have the perception that lower levels in the health care system provide lower quality care; therefore, they seek care at higher levels in the system, where specialists are concentrated ( 16 , 17 ). This preference for higher levels of care, even for simpler ailments, is not cost effective. In addition, a shortage of health workers across the health care system, especially at lower levels, lends credence to the client preference for higher, rather than lower, levels of care ( 1 ). Some of the policy challenges are lack of bypass policy. Incentives exist to use lower-level facilities, such as provision of services free of charge in levels 2 and 3 facilities, but Kenya does not have a referral bypass policy. It has no policy to require clients to report at levels appropriate for the management of their health needs, which often results in inappropriate self-referral to higher levels of care ( 8 ). Patients often refer themselves to higher levels of care bypassing lower-level facilities. The need to have efficient delivery of health care services at the different levels in terms of rational use of health care services and equitable services to the rural and the poor populations cannot be over-emphasized. Due to inadequate knowledge on the organization of services and the perceived low quality of services offered at lower levels, clients often by-pass available services at those lower levels where services could be provided more cost effectively. In order to provide health services equitably and cost-effectively, there is need to strengthen the referral system. For all the health care service delivery levels to provide the much-needed health services equitably and cost-effectively, the referral system needs to be strengthened. Kenyatta National Hospital (KNH) was established as a National Referral and Teaching Hospital, to provide training and medical research. KNH was established in 1901 and became a State Corporation in 1987 and sits at the peak of the health referral system in Kenya ( 18 ). According to the KNH Board order of 1987 contained in the Legal Notice No. 109, the functions of KNH were spelled out as a) to receive patients on referral for specialized health care; b) to provide facilities for medical education for the University of Nairobi and other health allied courses; c) to contribute to national health planning ( 18 ). This understanding has been reinforced by the Kenya Health Sector Referral Implementation Guidelines, 2014, and the Constitution of Kenya 2010 which tasks KNH with the responsibility for health policy formulation ( 3 , 19 ). For a referral system to be considered well-functioning, it needs to have active collaboration between referral levels and standardized referral protocols for the referring and receiving facilities and government support of the referral system through referral health policy ( 1 , 20 – 22 ). A standardized referral form should be used for all referral cases, as provided in the national referral guidelines. Every patient referred out should be accompanied by a written record of the clinical findings, the treatment given before referral, and a specific reason for making the referral. A carefully completed referral form can help a client receive timely attention at the receiving facility and improve health outcomes ( 3 , 6 – 8 ). Roles and responsibility of the referring health facility is to complete the standard referral form with all the necessary information and attach relevant documentation that are complete and legible ( 6 ). However, low utilization of the referral forms is common ( 1 , 23 , 24 ). Therefore, the objective of this study was to determine if the enforcement of the national referral guidelines at KNH influences the use of formal referral letters. Methods and Materials Study design This was a pre-post-test study design. The national referral implementation guideline was enforced on 1st July, 2021. The pretest covered 5 months before enforcement of referral guidelines (February 1, to June 30, 2021) while post-test covered 5 months after enforcement of the referral guidelines (August 1, to December 31, 2021). The variables compared were socio-demographic factors namely age, sex, marital status, religion, occupation, education level, type of health facility, health facility tier, and nature of admission before and after enforcement of the referral guidelines. Enforcement of referral guidelines required that the referring health facility consults with KNH referral Office for concurrence before patients are referred to KNH and that patients should come with written official referral letters. This was to ensure only patients who require specialized orthopaedic and trauma care not available at the peripheral health facilities get referred to KNH. Study area KNH is the largest teaching and referral hospital in East and Central Africa. KNH Orthopaedic Wards were the study area. KNH is based in Upperhill, Nairobi, the capital city of Kenya. It is located along Hospital Road, about 5km from the city centre. KNH has a bed capacity of 1,800, 6,000 + staff members, 50 wards, 22 out-patient clinics, 24 theaters (16 specialized) and Accident & Emergency Department ( 18 ). Of the 1800 bed capacity, 96 beds are allocated to orthopaedic wards. KNH is a 10-floor storied building complex and the Orthopaedic wards are located on the 6th floor but we also have orthopaedic admissions in private wings on 9th and 10th floor. Orthopaedic patients with other co-morbidities also get admitted to other wards in KNH. Study duration The study duration was from 1st February 2021 to 31st December 2021. The referral guidelines were enforced from 1st July 2021. Study population Orthopaedic inpatient caseload before and after enforcement of referral guidelines. Eligibility criteria Inclusion criteria All orthopaedic and trauma facility referrals to KNH during the study period. Sample size calculation Sample size was calculated using an adjusted Casagrande formula for calculating sample sizes that compare two binomial distributions ( 25 ). A sample size of 468 facility referrals were enrolled during the study period with 220 and 248 facility referrals before and after the enforcement of national referral guidelines. Recruitment and sampling procedures Three ( 3 ) research assistants (RAs) were recruited to collect and abstract patient data from patient files. The RAs were health care workers with a diploma in Orthopedic Trauma and with some experience in research data collection. The Principal Investigator (PI) was the research coordinator for the data collection. The orthopedic and trauma admissions with facility referrals were identified from the a) admission desk of Health Information System at KNH Accident and Emergency Unit (A&E) b) KNH Orthopedic Outpatient clinic records (OC) c) KNH Corporate Outpatient Care (COC). They were then recorded in a logbook. This logbook served as a master register for all facility referred patients admitted and therefore the sampling frame for the study. All facility admissions were logged into the logbook from the admission books stationed in these three ( 3 ) services points. Proportional Population to Size (PPS) was then used to decide on the numbers to be sampled per month from each of these three services points so that the sample size would be a representative of the admissions by month from each of these three orthopedic admissions entry points (Table 3 ). Table 3 Orthopaedic and trauma facility referrals admissions to KNH stratified by point of admission, 2021 Month of the year, 2021` Point of admission A&E Clinic COC Total Before February 52 3 3 58 March 40 1 3 44 April 37 0 3 40 May 33 2 2 37 June 39 1 1 41 Total 201 7 12 220 After August 42 2 2 46 September 52 3 4 59 October 55 2 4 61 November 22 0 12 32 December 43 2 3 48 Total 214 9 25 248 The three ( 3 ) RAs were reporting to and working under the direction of the PI. The RAs were trained for two ( 2 ) days by the PI on the research protocol, data collection tools, data collection procedures and that included pilot testing of the data collection tools as well before the actual data abstraction. A written Informed consent was obtained from KNH Medical Research Department to have access to the patient’s health records in the Health Information Office (Room 19). Variables The variables abstracted were admission date (dd/mm/yyyy), age of the patient, sex, marital status, religion, occupation, education level, type of health facility, health facility tier, and nature of admission. Data collection procedures Data collection was done through a data abstraction form from the patient files. Data Abstraction form – The three ( 3 ) RAs were trained on the data abstraction using a data abstraction form as per the research protocol. The PI reviewed all the filled-in abstraction forms for completeness and accuracy daily during the entire data collection period and providing regular feedback to the RAs on a timely manner to ensure data quality and compliance to the study protocol. All the completed and verified data abstraction forms were then collected and filed by the PI at the end of every week under a lockable cabinet. Data management, analysis, and presentation plan Data abstraction tool was designed to collect quantitative and qualitative data. For anonymity and confidentiality purposes the data abstraction tool were marked only with the participant study numbers and no names were used. The data were entered into a password-protected Redcap database kept by the KNH Medical Research Department. The data were analyzed using SPSS version 21.0. Descriptive statistics such as frequencies while inferential statistics using Pearson’s chi-squared tests, logistic regression were used. The calculations were done at a 95% level of confidence. Results The socio-demographic profile of the sample population The total number of charts abstracted was 468 charts with 220 charts before and 248 charts after the enforcement of the referral guidelines. Based on age groups, children represented 34 (12.5%) and 26 (10.5%) of the orthopedic and trauma admissions before and after enforcement of the referral guidelines respectively while majority of the admissions, 141 (64.1%) and 161 (64.9%) were observed among age group 25–64 years old before and after respectively. Orthopedic and trauma admissions above 65 years of age represented 8 (3.6%) and 10 (4.0%) before and after enforcement of the referral guidelines respectively (Table 1 ). Orthopedic and trauma admissions who were male before and after enforcement of referral regulations were 185 (84.5%) and 189 (76.8%) respectively (Table 1 ). Over 70% of the facility referrals had primary and secondary level of education before and after enforcement of the referral guidelines. Patients with preschool level of education or less represented 11.5% and 7.0% of facility referrals before and after enforcement of referral guidelines. Facility referrals with those with tertiary level of education represented 14.7% and 21.3% of orthopedic and trauma admissions (Table 1 ). Table 1 Profile of socio-demographic characteristic of orthopaedic and trauma admissions to KNH before and after enforcement of referral guidelines, 2021. Characteristics Before (n = 220) After (n = 248) Age 0–14 years 34 (15.5%) 26 (10.5%) 15–24 years 37 (16.8%) 51 (20.6%) 25–64 years 141 (64.1%) 161 (64.9%) Above 65 years 8 (3.6%) 10 (4.0%) Total 220 (100.0%) 248 (100.0%) Sex Female 34 (15.5%) 57 (23.2%) Male 185 (84.5%) 189 (76.8%) Total 219 (100.0%) 246 (100.0%) Missing* Marital status Married 103 (46.8%) 118 (47.8%) Minor 36 (16.4%) 32 (13.0%) Separated & Divorced 9 (4.1%) 14 (5.7%) Single 66 (30.0%) 79 (32.0%) Widow 6 (2.7%) 4 (1.6%) Total 220 (100.0%) 247 (100.0%) Missing* Religion Atheist 0 (0.0%) 1 (0.4%) Christian 214 (98.2%) 240 (97.2%) Hindu 1 (0.5%) 2 (0.8%) Muslim 3 (1.4%) 4 (1.6%) Total 218 (100.0%) 247 (100.0%) Missing* Occupation Businessman/woman 31 (14.2%) 25 (10.2%) Casual 94 (43.1%) 119 (48.4%) Employed 27 (12.4%) 38 (15.4%) Other 20 (9.2%) 12 (4.9%) Unemployed 46 (21.1%) 52 (21.1%) Total 218 (100.0%) 246 (100.0%) Missing* Education level None & Pre-school 25 (11.5%) 17 (7.0%) Primary 74 (33.9%) 96 (39.3%) Secondary 87 (39.9%) 79 (32.4%) Tertiary 32 (14.7%) 52 (21.3%) Total 218 (100.0%) 244 (100.0%) Missing* Effect of the enforcement of referral guidelines on use of official written referral letters Amongst the health facility referrals about 48.6% and 48.8% before and after enforcement of referral guidelines had referral letters (Table 2 ). There was a slight increase in number of facility referrals after the enforcement of the referral guidelines for patients with and without the referral letters ( p = 0.524) (Table 2 ). In addition, the odds ratio of the use of official written referral letters before and after the enforcement of referral guidelines was comparable (Table 2 ). Table 2 Facility referrals with referral letters before and after enforcement of referral guidelines, 2021 Have referral letters? Before (n = 220) After (n = 248) Χ²; p -value OR (95%CI) Facility referrals No 113 (51.4%) 127 (51.2%) 0.001; p = 0.524 1.0 Yes 107 (48.6%) 121 (48.8%) 0.994 (0.691–1.429) Amongst those with no written referral letters, patients with primary and tertiary level of education were 77.3% (p = 0.006) and 60.1% (p = 0.025) less likely to have no written referral letters as compared with patients with no education or preschool level of education after enforcement of the referral guidelines (Table 3 ). Amongst those with the written referral letters, females were twice more likely to have a written referral letter as compared to males after enforcement of the referral guidelines (p = 0.033) (Table 3 ). Table 3 Table showing use of referral letters by key socio-demographic characteristics stratified before and after enforcement of referral guidelines, 2021. Variable Have a referral letter? Categories Before After p-value OR (p-value) County No Others 7 (31.8%) 15 (68.2%) p = 0.368 - Kajiado 7 (35.0%) 13 (65.0%) Kiambu 10 (45.5%) 12 (54.5%) Nairobi 78 (50.0%) 78 (50.0%) Others - Eastern 11 (55.0%) 9 (45.0%) Total 113 (47.1%) 127 (52.9%) Yes Others 11 (39.3%) 17 (60.7%) p = 0.860 - Kajiado 10 (43.5%) 13 (56.5% Kiambu 21 (52.5%) 19 (47.5%) Nairobi 54 (47.8%) 59 (52.2%) Others - Eastern 11 (45.8%) 13 (54.2%) Total 107 (46.9%) 121 (53.1%) Education No None & Preschool 17 (64.0%) 9 (36.0%) p = 0.038 1.0 Primary 41 (45.1%) 50 (54.9%) 0.227 (p = 0.006) Secondary 43 (51.8%) 40 (48.2%) 0.523 (p = 0.109) Tertiary 12 (30.0%) 28 (79.0%) 0.399 (p = 0.025) Total 113 (46.9%) 127 (53.1%) Yes None & Preschool 9 (52.9%) 8 (47.1%) p = 0.508 - Primary 33 (41.8%) 46 (58.2%) Secondary 44 (53.0%) 39 (47.0%) Tertiary 20 (45.5%) 24 (54.5%) Total 106 (47.5%) 117 (52.5%) Sex No Female 20 (41.7%) 28 (58.3%) p = 0.420 - Male 92 (48.2%) 99 (51.8%) Total 112 (46.9%) 127 (53.1%) Yes Female 14 (32.6%) 29 (67.4%) p = 0.031 1.0 Male 93 (50.8%) 90 (49.2%) 2.140 (p = 0.033) Total 107 (47.3%) 119 (52.7%) Amongst those with written referral letters, patients from health facilities tiers 3 were 98.9% more likely to have written referral letter after enforcement of referral guidelines as compared to those from health facilities tier 1 (p = 0.011) (Table 4 ). However, the use of written referral letters for other health facility tiers were comparable with health facility tiers 1 (Table 4 ). Amongst patients with referral letters, elective patients were at least 3 times more likely to have referral letters as compared to emergency referrals after enforcement of the referral letters (p = 0.003) (Table 4 ). Table 4 Table showing use of referral letters for type of health facility, health tiers and nature of admissions stratified before and after enforcement of referral guidelines, 2021. Variable Have a referral letter? Categories Before After p-value OR (95%CI) Type of health facility No Government 76 (48.7%) 80 (51.3%) p = 0.489 - Private 37 (44.0%) 47 (56.0%) Total 113 (47.1%) 127 (52.9%) Yes Government 64 (48.1%) 69 (51.9%) p = 0.670 - Private 43 (45.3%) 52 (54.7%) Total 107 (46.9%) 121 (53.1%) Health facility tiers No Tier 2 2 (28.6%) 5 (71.4%) p = 0.635 - Tier 3 6 (60.0%) 4 (40.0%) Tier 4 46 (46.0%) 54 (54.0%) Tier 5 56 (49.1%) 58 (50.9%) Tier 6 3 (33.3%) 6 (66.7%) Total 113 (47.1%) 127 (52.9%) Yes Tier 2 11 (91.7%) 1 (8.3%) p = 0.002 1.0 Tier 3 9 (45.0%) 11 (55.0%) 0.011 (p = 0.003) Tier 4 33 (39.8%) 50 (60.2%) 0.153 (p = 0.103) Tier 5 53 (51.0%) 51 (49.0%) 0.189 (p = 0.125) Tier 6 1 (11.1%) 8 (88.9%) 0.120 (p = 0.050) Total 107 (46.9%) 121 (53.1%) Nature of admissions No Elective 12 (41.4%) 17 (58.6%) p = 0.483 - Emergency 101 (48.3%) 108 (51.7%) Total 113 (47.5%) 125 (52.5%) Yes Elective 5 (23.8%) 16 (76.2%) p = 0.026 1.0 Emergency 101 (49.3%) 104 (50.7%) 3.108 (p = 0.033) Total 106 (46.9%) 120 (53.1%) Discussion Children and elderly represented the minority admissions while youth and middle-aged patients were the majority of orthopedic and trauma admissions. This compares with studies done in Uganda, Rwanda, Botswana, South Africa, Nigeria, India, Taiwan, Brazil, England and USA that showed vast majority of orthopedic and trauma patients are young and middle- aged ( 26 – 38 ). Studies in Nigeria, Taiwan also showed children and the elderly form a small proportion of orthopedic and trauma injuries ( 30 , 35 ). However, this contrasts with a study done in PCEA Kikuyu Mission Hospital, Kenya that showed 18.84% orthopaedic admissions were of paediatric age group ( 39 ). This could be due to the fact that PCEA Kikuyu Mission Hospital is a private mission hospital and is a specialized and highly regarded orthopaedic and trauma centre in Kenya. The fact that majority of the admissions in this study were youth and middle-aged is likely due to the fact that these are the most productive age group involved in a wide-range of economic activities that require frequent use of road transport. Majority of the orthopedic and trauma admissions were male. This compares favorably with studies done in Rwanda, Uganda, Tanzania, Botswana, South Africa, India, Taiwan, England that showed male sex are the majority of orthopedic and trauma admissions ( 29 , 30 , 32 , 34 , 36 – 38 , 40 – 42 ). Men are bread winners in most families and therefore more likely to engage in risky and violent activities as they fend for their families. Majority of the facility referrals had primary and secondary level of education with those with tertiary and pre-school education and less representing the minority. This is in tandem with study done on injury characteristics in Moshi, Tanzania that revealed majority have primary and secondary level of education ( 43 ). This maybe because the facility is a tertiary health facility in an Urban setting in Tanzania, similar to KNH in Kenya. However, it contradicts a study done in rural Tanzania that showed majority of the referrals had no schooling or had primary levels of education ( 14 ). This could be due to the fact that the study was done amongst antenatal mothers in rural Tanzania where women, who tend to have lower or no education and form the bulk of rural population in Tanzania just like other sub-Saharan African countries. About half of facility referrals had written referral letters. This contradicts an assessment done on state of health referral system in Kenya in 2013 and in Afghanistan amongst sick children that showed about one-third of referrals had a referral slip ( 1 , 44 ). However, this study also included the community health units. The study findings also contradict studies done in Kenya, Uganda, Burkina Faso and Nigeria that showed high adherence to the referral guidelines with over two-thirds of facility referrals use formal referral letters ( 9 , 45 – 47 ). The comparatively low use of referral letters in the current study could be because most of the referrals were verbal over the telephone and once a verbal consensus had been reached, the referring health facilities did not see the need of writing a formal written referral letter. The study findings also contrast with studies on adherence to referral guidelines and use of referral letters in Cape Town, South Africa, Kenya, Malawi and United States of America that revealed majority adhered to referral guidelines with use of formal referral letters ( 41 , 48 – 51 ). This is likely due to the fact these health facilities were highly specialized treatment centres for Burn patients. This study revealed that the enforcement of the referral guidelines had no impact on the use of official written referral letters as per national referral guidelines requirements despite increase in the facility referrals resulting from enforcement of national referral guidelines. Its therefore critical that further studies be done to understand the challenges, barriers and obstacles to the use of standard referral forms in patient referrals. Patients with higher education level were more likely to have written referral letter after enforcement of the referral guidelines. This is in tandem with a study done in Western Kenya on referrals for hypertension that revealed patients with higher education level were likely to receive a referral letter ( 52 ). This may be because they are more informed and would need to know the details and why they are referred and appreciate the significance of formal communication to ease access to services at the next level of care. Females were more likely than men to have a written referral letter after enforcement of the referral guidelines. This maybe because women are known to have better health seeking behavior than men. However, this contradicts a study done in Western Kenya on referrals for hypertension that revealed male patients were likely to receive a referral letter ( 52 ). This may be because more older women were admitted after enforcement of the referral guidelines and these women were more-educated, had insurance cover and were therefore more likely to require a formal written referral letter to facilitate smooth referral process to the next level of care. The use of written referral letters across most of the health facility tiers remained unchanged after enforcement of referral guidelines, patients with from health facilities tier 2 were less likely to have written referral letter after enforcement of the referral letter than tier 3 health facilities referrals. This could be explained by the fact that once the referring health facility have called and informed KNH of the need for referral, they saw no need to follow it up with a written referral letter. This ties in with an evaluation on the state of health referral system in Kenya that revealed that the use of oral referrals comprised about a third of the referrals with the use of the referral form comprising another one-third of the referrals ( 1 ). In addition, tier 2 health facilities were mostly small private clinics and these health facilities in most cases are non-compliant to the government standards and guidelines and are mostly located within the poor settlements in Nairobi and “less accessible” during the supervisory visits by the county health management staff. Level three health facilities are government and private nursing and maternity homes that are relatively high volume and frequently supervised by the county health management staff and are more likely to be compliant to the government’s standards and guidelines. Elective patients were more likely than emergency patients to have a written referral letter. This could be due to the fact that emergency traumatic injuries were done through telephone conversations between the referring health facility and KNH and once an agreement had been reached, the referring health facility found no need to have an official referral letter. This is in tandem with the Kenya referral guidelines stipulates for emergency referrals, the referring health worker communicates directly by phone or any other means of communication available to the receiving health worker to ensure that advance notice of the referral is given to allow adequate preparation ( 6 ). However, this contradicts a study done in Afghanistan amongst sick children that showed use of referral slips by health care providers was higher for urgent referrals ( 44 ). This study had some limitations. First, the effect of COVID 19 pandemic on facility referrals of cases from peripheral health facilities to KNH. This was mitigated by ensuring the data collection period covered the covid period where intercounty movement restrictions were lifted by the Kenyan government. Secondly, this was a retrospective quasi-experimental study design and hence weaker in determining causality. Despite these limitations, given the paucity of published literature in this study topic, this study offers key information on the effects of enforcement of referral guidelines on use of written referral letters in health facility referrals to KNH with important lessons for Kenya and possible sub-Saharan Africa. Conclusion The enforcement of the national referral guidelines had no effect on the use of the official written referral letters as per the requirement of the national referral guidelines amongst the orthopedic and trauma admissions at KNH. Majority of the facility referrals were young and middle-aged men with children and elderly representing the minority. Most of the facility referrals had had primary and secondary level of education with admissions. Women, elective patients and those with higher education were more likely to have a written referral letter. Recommendations Further studies are needed to understand the obstacles, challenges and barriers towards use of official referral letter; Need for an effective referral system monitoring; Need for capacity building of health care workers on effective referral process by designing and disseminating referral SOPs and standardized documentation for referrals; Need for referral coordinating and review forums – to review coordination, encourage accountability and continuous improvement and referral performance monitoring; Improving the capacity and attitude of service providers at all levels of the health system on use of written referral letters; Introduce new technology of e-health, such as telemedicine, e-referrals, and e-mail, to improve the referral documentation system. List Of Abbreviations COVID Corona Virus Disease ERC Ethics Review Committee KNH Kenyatta National Hospital UoN/KNH University of Nairobi/Kenyatta National Hospital RA Research Assistant SPSS Statistical Package for the Social Sciences SOPs Standard Operating Procedures USA United States of America PCEA Presbyterian Church of East Africa PI Principal Investigator Declarations Ethics approval and consent to participate The study protocol was presented to University of Nairobi/Kenyatta National Hospital (UoN/KNH) Ethics and Research Committee and was granted ethical approval (ERC No: P852/10/2021). Administrative approval was also granted by KNH Medical Research Department and KNH Orthopaedics Department. Consent for publication Not Applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The author declares no competing interest exists Funding This study was partially funded by Kenyatta National Hospital. RFA 2020/2021. The funders had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions The author conceptualized, designed, collected data, analyzed and drafted the manuscript. Acknowledgements I would like to sincerely acknowledge the work of Brian Okinyi and Micah J. Kipkemei for commitment and assistance in data collection process. References MoH. The State of the Health Referral System in Kenya: Results from a Baseline Study on the Functionality of the Health Referral System in Eight Counties In: Unit HSMaE, editor. Nairobi, Kenya; 2013. Ministry of Devolution and Planning KM. The Kenya Vision 2030: The Second Medium-Term Plan 2013–2017. Transforming Kenya: Pathway to devolution, socio-economic development, equity and national unity. In: Treasury, editor. Nairobi, Kenya; 2013. MoH. Kenya Health Policy 2014 – 2030. Nairobi, Kenya; 2014. (MoH) MoH. Reversing the trends. The Second National Health Sector Strategic Plan of Kenya – NHSSP II 2005–2010. In: Secretariat HSR, editor. Nairobi, Kenya: Ministry of Health; 2005. (MOH) MoHK. Sessional Paper No. 6 of 2012 of the Kenya Health Policy 2012–2030. In: Unit HSR, editor. Nairobi, Kenya: Ministry of Health Kenya; 2013. MoH. Kenya Health Sector Referral Implementation Guidelines. In: Health, editor. 1st ed. Nairobi, Kenya; 2014. MoH. Kenya Health Sector Referral Strategy (2014 - 2018). In: Management DoEaDR, editor. Nairobi, Kenya; 2014. MoH. Ministry of Health, Kenya. Health Sector Referral Strategy 2014 - 2018. Nairobi; 2014. Ilboudo TP, Chou YJ, Huang N. Compliance with referral for curative care in rural Burkina Faso. Health Policy Plan. 2012 May;27(3):256-64. Darmstadt GL, El Arifeen S, Choi Y, Bari S, Rahman SM, Mannan I, et al. Household surveillance of severe neonatal illness by community health workers in Mirzapur, Bangladesh: coverage and compliance with referral. Health Policy Plan. 2010 Mar;25(2):112-24. Font F, Quinto L, Masanja H, Nathan R, Ascaso C, Menendez C, et al. Paediatric referrals in rural Tanzania: the Kilombero District Study - a case series. BMC Int Health Hum Rights. 2002 Apr 30;2(1):4. Kallander K, Tomson G, Nsungwa-Sabiiti J, Senyonjo Y, Pariyo G, Peterson S. Community referral in home management of malaria in western Uganda: a case series study. BMC Int Health Hum Rights. 2006 Mar 16;6:2. Peterson S, Nsungwa-Sabiiti J, Were W, Nsabagasani X, Magumba G, Nambooze J, et al. Coping with paediatric referral--Ugandan parents' experience. Lancet. 2004 Jun 12;363(9425):1955-6. Kruk ME, Mbaruku G, McCord CW, Moran M, Rockers PC, Galea S. Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania. Health Policy Plan. 2009 Jul;24(4):279-88. Hensher M, Price M, Adomakoh S. Referral Hospitals. 2006. London L, Bachmann OM. Paediatric utilisation of a teaching hospital and a community health centre. Predictors of level of care used by children from Khayelitsha, Cape Town. S Afr Med J. 1997 Jan;87(1):31-6. Nolan T, Angos P, Cunha AJ, Muhe L, Qazi S, Simoes EA, et al. Quality of hospital care for seriously ill children in less-developed countries. Lancet. 2001 Jan 13;357(9250):106-10. MoH. Nairobi; 2021 [updated 2021; cited 2021 10th May ]; Available from: https://knh.or.ke/index.php/history/ GoK. Article 6 of the Constitution of Kenya 2010. Nairobi, Kenya; 2010. Murray SF, Davies S, Phiri RK, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan. 2001 Dec;16(4):353-61. Ricca J, Negroustoueva S. Development of a Monitoring Framework for Referral within a Network of HIV/AIDS Service Providers: Condensed Final Report Based on Four Case Studies. Journal [serial on the Internet]. 2009 Date: Available from: https://www.measureevaluation.org/resources/publications/sr-09-58b.html. Federal Democratic Republic of Ethiopia MoHM. Guidelines for implementation of a patient referral system. Addis Ababa, Ethiopia. In: Directorate MS, editor. Addis Ababa, Ethiopia; 2010. Ohara K, Melendez V, Uehara N, Ohi G. Study of a patient referral system in the Republic of Honduras. Health Policy Plan. 1998 Dec;13(4):433-45. Nordberg E, Holmberg S, Kiugu S. Exploring the interface between first and second level of care: referrals in rural Africa. Trop Med Int Health. 1996 Feb;1(1):107-11. Casagrande JT, Pike MC, Smith PG. An improved approximation formula for calculating sample sizes for comparing two binomial distributions. Biometrics 1978; 34:483-6 Jain A, Goyal V, Varma C. Reflection of Epidemiological Impact on Burden of Injury in Tertiary Care Centre, Pre-COVID and COVID Era: "Lockdown, a Good Fortune for Saving Life and Limb". Indian J Surg. 2020 Oct 24:1-5. Ovadia P, Szewczyk D, Walker K, Abdullah F, Schmidt-Gillespie S, Rabinovici R. Admission patterns of an urban level I trauma center. Am J Med Qual. 2000 Jan-Feb;15(1):9-15. Stonko DP, Dennis BM, Callcut RA, Betzold RD, Smith MC, Medvecz AJ, et al. Identifying temporal patterns in trauma admissions: Informing resource allocation. PLoS One. 2018;13(12):e0207766. Saikiran V., Laxmi P. G, Nagaraju V., Bharath K. D, Shyam S. A. Epidemiology of orthopedic trauma admissions in a multispecialty hospital in Warangal-A retrospective study. Clinical Practice. 2019;16(6). Pan RH, Chang NT, Chu D, Hsu KF, Hsu YN, Hsu JC, et al. Epidemiology of orthopedic fractures and other injuries among inpatients admitted due to traffic accidents: a 10-year nationwide survey in Taiwan. ScientificWorldJournal. 2014;2014:637872. Bedada AG, Tarpley MJ, Tarpley JL. The characteristics and outcomes of trauma admissions to an adult general surgery ward in a tertiary teaching hospital. Afr J Emerg Med. 2021 Jun;11(2):303-8. Taylor A, Young. A. Epidemiology of Orthopaedic Trauma Admissions Over One Year in a District General Hospital in England. The open orthopaedics journal. [Journal]. 2015 29 May 9:191-3. Viel IL, Moura BRS, Martuchi SD, de Souza Nogueira L. Factors Associated With Interhospital Transfer of Trauma Victims. J Trauma Nurs. 2019 Sep/Oct;26(5):257-62. Manwana ME, Mokone GG, Kebaetse M, T Y. Epidemiology of traumatic orthopaedic injuries at Princess Marina Hospital, Botswana. South African Orthopaedic Journal. 2018 March 2018;17(1):41-6. Edomwonyi EO, Enemudo RE, Okafor IA. Pattern of Mortalities among Orthopaedic and Trauma Admissions in Irrua. Open Journal of Orthopedics. 2015;5(7). Dhaffala A, Longo-Mbenza B, Kingu JH, Peden M, Kafuko-Bwoye A, Clarke M, et al. Demographic profile and epidemiology of injury in Mthatha, South Africa. Afr Health Sci. 2013 Dec;13(4):1144-8. Theoneste N, Gabriel T, Jackline O, Rebecca M, Robert R, Neil G, et al. Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda. Global Surgery. 2016;160(6):1636-44. Nathan NO, Rodney M, Gerard PS, Maryse B. The Orthopedic Trauma Patient Experience: A Qualitative Case Study of Orthopedic Trauma Patients in Uganda. PLOS ONE. 2014;9(10). Kihuba E. Epidemiology and medical costs of orthopedic conditions in a tertiary hospital in Kenya; A five-year analysis of admission data. BMJ Yale. 2022. Vikas V, Sheela S, Girish KS, Santosh K, Ajay S, Kanika G. Distribution of Injury Patterns in Trauma Victims Admitted to the Trauma Centre of CSMMU, LUCKNOW. Indian Journal of Community Health. 2013;25(1):52-60. Pillay I, Mahomed OH. Prevalence and determinants of self-referrals to a District-Regional Hospital in KwaZulu Natal, South Africa: a cross sectional study. Pan Afr Med J. 2019; 33:4. Rutta E, Mutasingwa D, Ngallaba SE, Berege ZA. Epidemiology of injury patients at Bugando Medical Centre, Tanzania. East Afr Med J. 2001 Mar;78(3):161-4. Zimmerman A, Barcenas LK, Pesambili M, Sakita F, Mallya S, Vissoci JRN, et al. Injury characteristics and their association with clinical complications among emergency care patients in Tanzania. Afr J Emerg Med. 2022 Dec;12(4):378-86. Newbrander W, Ickx P, Werner R, Mujadidi F. Compliance with referral of sick children: a survey in five districts of Afghanistan. BMC Pediatr. 2012 Apr 27; 12:46. Njanwe PJ, Marete I, Ayaya S. Adherence to national healthcare referral guidelines and its effect on the management outcomes among children seen at a Teaching Hospital in western Kenya. East African Medical Journal. 2021;98(1). Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, et al. Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malar J. 2016 Nov 24;15(1):568. Akande T. Referral system in Nigeria: Study of a tertiary health facility. Annals of African Medicine. 2004;3(3):130 - 3. Boissin C, Hasselberg M, Kronblad E, Kim SM, Wallis L, Rode H, et al. Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Int J Environ Res Public Health. 2017 Jul 6;14(7). Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health. 2020 Jul;25(7):824-33. Carter JE, Neff LP, Holmes JHt. Adherence to burn center referral criteria: are patients appropriately being referred? J Burn Care Res. 2010 Jan-Feb;31(1):26-30. Alex M, Olivia CK, Gloria K, Philip B. Referral patterns at a regional faith-based hospital in Western Kenya. International Journal of Advanced Community Practice. 2021;4(4):36-40. Thakkar A, Valente T, Andesia J, Njuguna B, Miheso J, Mercer T, et al. Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study. BMC Health Serv Res. 2022 Mar 7;22(1):315. Additional Declarations No competing interests reported. Supplementary Files SPSSDataset31.12.2023.sav Cite Share Download PDF Status: Posted Version 1 posted 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-3962350","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276294596,"identity":"bc2882db-32a7-4fd7-9bb1-3c1989b7f182","order_by":0,"name":"Maxwell Philip Omondi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYNCCAgswJZFQASSZmRuI0GIgAdVyBqSFkRQtjG0gioAW3fYzZhIfDCTkdNt7D954OK82mr8dqOVHxTacWszOpKVJzjCQMDY7cy7ZInHb8dwZhxkbGHvO3Mat5UDysds8BhKJ227kmAHJY7kNQC3MjG14tJx/2Hb7D1zLnGO58wlquQG0hQGupaEmdwNhLc/Sf/aA/XLG2CLh2IHcjUAtB/H65XyOscGPChs5s+M9hjd/1NTlzjt/+OCDHxW4taCDw2DyANHqgaCOFMWjYBSMglEwQgAAYkFeopz2dNwAAAAASUVORK5CYII=","orcid":"","institution":"University of Nairobi","correspondingAuthor":true,"prefix":"","firstName":"Maxwell","middleName":"Philip","lastName":"Omondi","suffix":""}],"badges":[],"createdAt":"2024-02-16 20:45:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3962350/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3962350/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52105500,"identity":"5d27e103-7456-4c29-a69a-efa30a3bdb0c","added_by":"auto","created_at":"2024-03-06 19:28:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":204201,"visible":true,"origin":"","legend":"\u003cp\u003eKenya health care system with four tiers of care compared to the previous six levels of care(4, 5).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3962350/v1/ae536815825b9633f890dc1f.png"},{"id":103922960,"identity":"9a207d11-34e7-47ec-8e5f-1eafb58bb3c2","added_by":"auto","created_at":"2026-03-04 14:42:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1331633,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3962350/v1/b0d2e95f-4ad7-4019-b4c0-1907099ce26e.pdf"},{"id":52105502,"identity":"650ea93f-292b-4c39-b4c4-9c4535d6a2bd","added_by":"auto","created_at":"2024-03-06 19:28:18","extension":"sav","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1356182,"visible":true,"origin":"","legend":"","description":"","filename":"SPSSDataset31.12.2023.sav","url":"https://assets-eu.researchsquare.com/files/rs-3962350/v1/4845142dbc1d18671e122206.sav"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does a formal referral system work? Case study of a tertiary teaching and referral hospital in Kenya: Pre-posttest study","fulltext":[{"header":"Background","content":"\u003cp\u003eReferral is a mechanism to comprehensively manage clients\u0026rsquo; health needs by using resources beyond those available where they access care. It is the process by which a given level of health services that has inadequate capacity to manage a given health condition or event seeks the assistance of a higher level of healthcare delivery to guide or take over the management of the condition. With this approach, the Kenya health sector has developed a referral strategy, standard guidelines, and forms to guide the sector in building an effective system that responds to the needs of both rural and poor populations and in the process improve equitable access to quality health services to all Kenyans in an effort to reverse the declining health indicators. In this way, the health sector can contribute towards Kenya\u0026rsquo;s realization of Vision 2030, the Millennium Development Goals, and other health-related targets (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Kenya Health Policy 2012\u0026ndash;2030 has identified the need to strengthen the referral system in Kenya as a way of improving efficiency in the health system and improving patient outcomes. In the 2012\u0026ndash;2018 Kenya Health Sector Strategic and Investment Plan (KHSSP 2012\u0026ndash;2018), referral systems strengthening is one of the seven priority areas under investment area one of service delivery systems. Some of the critical investment priorities for the referral system outlined in the KHSSP 2012\u0026ndash;2018 include (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) updated referral tools and guidelines at all levels (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) orientation of the management teams on their referral roles and functions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). According to Kenya Medium Term plan 2013\u0026ndash;2017, increasing the utilization of services at lower levels of the health services and reduce self-referral to the higher levels of care is one of the key priorities to improve access to health care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKenya devolved system of government provides for one (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) national government and forty-seven (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) county governments. The Fourth Schedule of the Constitution, has assigned different functions to the two levels of government. In the devolved system, the mandate of the national-level MOH consists of provision of care and management of the national referral health facilities, formulation of health policy, development of norms, standards and guidelines, and provision of capacity building and technical assistance for the counties. The mandate of the counties includes, among others, the provision of health services and management of referrals in county health facilities and pharmacies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe delivery of the Kenya Essential Package for Health (KEPH) health services in Kenya is organized across six levels of care, beginning at the community level and continuing through primary care services, which include dispensaries (level 2) and health centers (level 3) and county referral health services (level 4 \u0026amp; 5) all the way to the national referral health services (level 6) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The strengthening of referral linkages across service delivery units is one of the elements in the health policy strategy to achieve an efficient health service delivery system that maximizes health outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Level 4 are primary referral health facilities; level 5 are secondary referral health facilities and level 6 are tertiary referral health facilities. These six levels of care fits into 4 tiers of care. The first tier consists of the community health units. The second tier consists of the primary health care facilities that have dispensaries, health centers and private maternity and nursing homes. The third tier consists of the county referral facilities, which include the former primary and secondary hospitals. The fourth tier, the national referral facilities that offer highly specialized care, is used for training and support research (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Health facilities in the various tiers of care include government-owned facilities, faith-based organizations, and private health institutions. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome of the challenges in health referral systems in most developing countries include noncompliance with referrals (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) delays in referral completion (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) high numbers of self-referrals to higher-level referral facilities (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This is because of lack of awareness on where to get cost-effective health services for different conditions, perception that lower levels of care provide lower quality of care for uncomplicated health conditions, the system delays referrals to the next level of care in cases when complications require an emergency intervention and lack of primary care facilities within geographical reach of the clients and the fact that the tertiary health facilities are the closest facilities (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Many people have the perception that lower levels in the health care system provide lower quality care; therefore, they seek care at higher levels in the system, where specialists are concentrated (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This preference for higher levels of care, even for simpler ailments, is not cost effective. In addition, a shortage of health workers across the health care system, especially at lower levels, lends credence to the client preference for higher, rather than lower, levels of care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Some of the policy challenges are lack of bypass policy. Incentives exist to use lower-level facilities, such as provision of services free of charge in levels 2 and 3 facilities, but Kenya does not have a referral bypass policy. It has no policy to require clients to report at levels appropriate for the management of their health needs, which often results in inappropriate self-referral to higher levels of care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Patients often refer themselves to higher levels of care bypassing lower-level facilities. The need to have efficient delivery of health care services at the different levels in terms of rational use of health care services and equitable services to the rural and the poor populations cannot be over-emphasized. Due to inadequate knowledge on the organization of services and the perceived low quality of services offered at lower levels, clients often by-pass available services at those lower levels where services could be provided more cost effectively. In order to provide health services equitably and cost-effectively, there is need to strengthen the referral system. For all the health care service delivery levels to provide the much-needed health services equitably and cost-effectively, the referral system needs to be strengthened.\u003c/p\u003e \u003cp\u003eKenyatta National Hospital (KNH) was established as a National Referral and Teaching Hospital, to provide training and medical research. KNH was established in 1901 and became a State Corporation in 1987 and sits at the peak of the health referral system in Kenya (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). According to the KNH Board order of 1987 contained in the Legal Notice No. 109, the functions of KNH were spelled out as a) to receive patients on referral for specialized health care; b) to provide facilities for medical education for the University of Nairobi and other health allied courses; c) to contribute to national health planning (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This understanding has been reinforced by the Kenya Health Sector Referral Implementation Guidelines, 2014, and the Constitution of Kenya 2010 which tasks KNH with the responsibility for health policy formulation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor a referral system to be considered well-functioning, it needs to have active collaboration between referral levels and standardized referral protocols for the referring and receiving facilities and government support of the referral system through referral health policy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). A standardized referral form should be used for all referral cases, as provided in the national referral guidelines. Every patient referred out should be accompanied by a written record of the clinical findings, the treatment given before referral, and a specific reason for making the referral. A carefully completed referral form can help a client receive timely attention at the receiving facility and improve health outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Roles and responsibility of the referring health facility is to complete the standard referral form with all the necessary information and attach relevant documentation that are complete and legible (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, low utilization of the referral forms is common (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Therefore, the objective of this study was to determine if the enforcement of the national referral guidelines at KNH influences the use of formal referral letters.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a pre-post-test study design. The national referral implementation guideline was enforced on 1st July, 2021. The pretest covered 5 months before enforcement of referral guidelines (February 1, to June 30, 2021) while post-test covered 5 months after enforcement of the referral guidelines (August 1, to December 31, 2021). The variables compared were socio-demographic factors namely age, sex, marital status, religion, occupation, education level, type of health facility, health facility tier, and nature of admission before and after enforcement of the referral guidelines. Enforcement of referral guidelines required that the referring health facility consults with KNH referral Office for concurrence before patients are referred to KNH and that patients should come with written official referral letters. This was to ensure only patients who require specialized orthopaedic and trauma care not available at the peripheral health facilities get referred to KNH.\u003c/p\u003e\n\u003ch3\u003eStudy area\u003c/h3\u003e\n\u003cp\u003eKNH is the largest teaching and referral hospital in East and Central Africa. KNH Orthopaedic Wards were the study area. KNH is based in Upperhill, Nairobi, the capital city of Kenya. It is located along Hospital Road, about 5km from the city centre. KNH has a bed capacity of 1,800, 6,000\u0026thinsp;+\u0026thinsp;staff members, 50 wards, 22 out-patient clinics, 24 theaters (16 specialized) and Accident \u0026amp; Emergency Department (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). Of the 1800 bed capacity, 96 beds are allocated to orthopaedic wards. KNH is a 10-floor storied building complex and the Orthopaedic wards are located on the 6th floor but we also have orthopaedic admissions in private wings on 9th and 10th floor. Orthopaedic patients with other co-morbidities also get admitted to other wards in KNH.\u003c/p\u003e\n\u003ch3\u003eStudy duration\u003c/h3\u003e\n\u003cp\u003eThe study duration was from 1st February 2021 to 31st December 2021. The referral guidelines were enforced from 1st July 2021.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eOrthopaedic inpatient caseload before and after enforcement of referral guidelines.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAll orthopaedic and trauma facility referrals to KNH during the study period.\u003c/p\u003e\n\u003ch3\u003eSample size calculation\u003c/h3\u003e\n\u003cp\u003eSample size was calculated using an adjusted Casagrande formula for calculating sample sizes that compare two binomial distributions (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eA sample size of 468 facility referrals were enrolled during the study period with 220 and 248 facility referrals before and after the enforcement of national referral guidelines.\u003c/p\u003e\n\u003ch3\u003eRecruitment and sampling procedures\u003c/h3\u003e\n\u003cp\u003eThree (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) research assistants (RAs) were recruited to collect and abstract patient data from patient files. The RAs were health care workers with a diploma in Orthopedic Trauma and with some experience in research data collection. The Principal Investigator (PI) was the research coordinator for the data collection. The orthopedic and trauma admissions with facility referrals were identified from the a) admission desk of Health Information System at KNH Accident and Emergency Unit (A\u0026amp;E) b) KNH Orthopedic Outpatient clinic records (OC) c) KNH Corporate Outpatient Care (COC). They were then recorded in a logbook. This logbook served as a master register for all facility referred patients admitted and therefore the sampling frame for the study. All facility admissions were logged into the logbook from the admission books stationed in these three (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) services points. Proportional Population to Size (PPS) was then used to decide on the numbers to be sampled per month from each of these three services points so that the sample size would be a representative of the admissions by month from each of these three orthopedic admissions entry points (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOrthopaedic and trauma facility referrals admissions to KNH stratified by point of admission, 2021\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMonth of the year, 2021`\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003ePoint of admission\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA\u0026amp;E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFebruary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApril\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJune\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e220\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eAfter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAugust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeptember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOctober\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNovember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe three (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) RAs were reporting to and working under the direction of the PI. The RAs were trained for two (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) days by the PI on the research protocol, data collection tools, data collection procedures and that included pilot testing of the data collection tools as well before the actual data abstraction.\u003c/p\u003e\n\u003cp\u003eA written Informed consent was obtained from KNH Medical Research Department to have access to the patient\u0026rsquo;s health records in the Health Information Office (Room 19).\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003eThe variables abstracted were admission date (dd/mm/yyyy), age of the patient, sex, marital status, religion, occupation, education level, type of health facility, health facility tier, and nature of admission.\u003c/p\u003e\n\u003ch3\u003eData collection procedures\u003c/h3\u003e\n\u003cp\u003eData collection was done through a data abstraction form from the patient files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Abstraction form \u0026ndash;\u003c/strong\u003e The three (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) RAs were trained on the data abstraction using a data abstraction form as per the research protocol. The PI reviewed all the filled-in abstraction forms for completeness and accuracy daily during the entire data collection period and providing regular feedback to the RAs on a timely manner to ensure data quality and compliance to the study protocol. All the completed and verified data abstraction forms were then collected and filed by the PI at the end of every week under a lockable cabinet.\u003c/p\u003e\n\u003ch3\u003eData management, analysis, and presentation plan\u003c/h3\u003e\n\u003cp\u003eData abstraction tool was designed to collect quantitative and qualitative data. For anonymity and confidentiality purposes the data abstraction tool were marked only with the participant study numbers and no names were used. The data were entered into a password-protected Redcap database kept by the KNH Medical Research Department. The data were analyzed using SPSS version 21.0. Descriptive statistics such as frequencies while inferential statistics using Pearson\u0026rsquo;s chi-squared tests, logistic regression were used. The calculations were done at a 95% level of confidence.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eThe socio-demographic profile of the sample population\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The total number of charts abstracted was 468 charts with 220 charts before and 248 charts after the enforcement of the referral guidelines.\u003c/p\u003e \u003cp\u003e Based on age groups, children represented 34 (12.5%) and 26 (10.5%) of the orthopedic and trauma admissions before and after enforcement of the referral guidelines respectively while majority of the admissions, 141 (64.1%) and 161 (64.9%) were observed among age group 25\u0026ndash;64 years old before and after respectively. Orthopedic and trauma admissions above 65 years of age represented 8 (3.6%) and 10 (4.0%) before and after enforcement of the referral guidelines respectively (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOrthopedic and trauma admissions who were male before and after enforcement of referral regulations were 185 (84.5%) and 189 (76.8%) respectively (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Over 70% of the facility referrals had primary and secondary level of education before and after enforcement of the referral guidelines. Patients with preschool level of education or less represented 11.5% and 7.0% of facility referrals before and after enforcement of referral guidelines. Facility referrals with those with tertiary level of education represented 14.7% and 21.3% of orthopedic and trauma admissions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProfile of socio-demographic characteristic of orthopaedic and trauma admissions to KNH before and after enforcement of referral guidelines, 2021.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore (n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter (n\u0026thinsp;=\u0026thinsp;248)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (15.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;64 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e141 (64.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e161 (64.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove 65 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e248 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (15.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e185 (84.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e189 (76.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e219 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e246 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103 (46.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e118 (47.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (13.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeparated \u0026amp; Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (5.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (30.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79 (32.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e247 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAtheist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e214 (98.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e240 (97.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e218 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e247 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBusinessman/woman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCasual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94 (43.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e119 (48.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (12.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e218 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e246 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone \u0026amp; Pre-school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74 (33.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96 (39.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (39.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e218 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e244 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cb\u003e Effect of the enforcement of referral guidelines on use of official written referral letters\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmongst the health facility referrals about 48.6% and 48.8% before and after enforcement of referral guidelines had referral letters (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a slight increase in number of facility referrals after the enforcement of the referral guidelines for patients with and without the referral letters (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.524) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In addition, the odds ratio of the use of official written referral letters before and after the enforcement of referral guidelines was comparable (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFacility referrals with referral letters before and after enforcement of referral guidelines, 2021\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave referral letters?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore (n\u0026thinsp;=\u0026thinsp;220)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter (n\u0026thinsp;=\u0026thinsp;248)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eΧ\u0026sup2;;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFacility referrals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (51.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e127 (51.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001; p\u0026thinsp;=\u0026thinsp;0.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107 (48.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e121 (48.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003cp\u003e(0.691\u0026ndash;1.429)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmongst those with no written referral letters, patients with primary and tertiary level of education were 77.3% (p\u0026thinsp;=\u0026thinsp;0.006) and 60.1% (p\u0026thinsp;=\u0026thinsp;0.025) less likely to have no written referral letters as compared with patients with no education or preschool level of education after enforcement of the referral guidelines (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmongst those with the written referral letters, females were twice more likely to have a written referral letter as compared to males after enforcement of the referral guidelines (p\u0026thinsp;=\u0026thinsp;0.033) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable showing use of referral letters by key socio-demographic characteristics stratified before and after enforcement of referral guidelines, 2021.\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=\"left\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave a referral letter?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOR (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eCounty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15 (68.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKajiado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (65.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKiambu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNairobi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers - Eastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (55.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e127 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (39.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17 (60.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKajiado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKiambu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19 (47.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNairobi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54 (47.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e59 (52.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers - Eastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e107 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone \u0026amp; Preschool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (64.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.227 (p\u0026thinsp;=\u0026thinsp;0.006)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43 (51.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40 (48.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.523 (p\u0026thinsp;=\u0026thinsp;0.109)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (30.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28 (79.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.399 (p\u0026thinsp;=\u0026thinsp;0.025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e127 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone \u0026amp; Preschool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (41.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46 (58.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (53.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39 (47.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106 (47.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e117 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92 (48.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e99 (51.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e112 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e127 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (32.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29 (67.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e93 (50.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e90 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e2.140 (p\u0026thinsp;=\u0026thinsp;0.033)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e107 (47.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e119 (52.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmongst those with written referral letters, patients from health facilities tiers 3 were 98.9% more likely to have written referral letter after enforcement of referral guidelines as compared to those from health facilities tier 1 (p\u0026thinsp;=\u0026thinsp;0.011) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, the use of written referral letters for other health facility tiers were comparable with health facility tiers 1 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmongst patients with referral letters, elective patients were at least 3 times more likely to have referral letters as compared to emergency referrals after enforcement of the referral letters (p\u0026thinsp;=\u0026thinsp;0.003) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable showing use of referral letters for type of health facility, health tiers and nature of admissions stratified before and after enforcement of referral guidelines, 2021.\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=\"left\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave a referral letter?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eType of health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGovernment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76 (48.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80 (51.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37 (44.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47 (56.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e127 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGovernment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43 (45.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e52 (54.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e107 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eHealth facility tiers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46 (46.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54 (54.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (49.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e58 (50.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e127 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (91.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (55.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.011 (p\u0026thinsp;=\u0026thinsp;0.003)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50 (60.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.153 (p\u0026thinsp;=\u0026thinsp;0.103)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53 (51.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e51 (49.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.189 (p\u0026thinsp;=\u0026thinsp;0.125)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTier 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (88.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.120 (p\u0026thinsp;=\u0026thinsp;0.050)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e107 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eNature of admissions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (41.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17 (58.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e101 (48.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e108 (51.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e113 (47.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e125 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (23.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16 (76.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e101 (49.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e104 (50.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e3.108 (p\u0026thinsp;=\u0026thinsp;0.033)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e120 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChildren and elderly represented the minority admissions while youth and middle-aged patients were the majority of orthopedic and trauma admissions. This compares with studies done in Uganda, Rwanda, Botswana, South Africa, Nigeria, India, Taiwan, Brazil, England and USA that showed vast majority of orthopedic and trauma patients are young and middle- aged (\u003cspan additionalcitationids=\"CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Studies in Nigeria, Taiwan also showed children and the elderly form a small proportion of orthopedic and trauma injuries (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, this contrasts with a study done in PCEA Kikuyu Mission Hospital, Kenya that showed 18.84% orthopaedic admissions were of paediatric age group (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). This could be due to the fact that PCEA Kikuyu Mission Hospital is a private mission hospital and is a specialized and highly regarded orthopaedic and trauma centre in Kenya. The fact that majority of the admissions in this study were youth and middle-aged is likely due to the fact that these are the most productive age group involved in a wide-range of economic activities that require frequent use of road transport.\u003c/p\u003e \u003cp\u003eMajority of the orthopedic and trauma admissions were male. This compares favorably with studies done in Rwanda, Uganda, Tanzania, Botswana, South Africa, India, Taiwan, England that showed male sex are the majority of orthopedic and trauma admissions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Men are bread winners in most families and therefore more likely to engage in risky and violent activities as they fend for their families.\u003c/p\u003e \u003cp\u003eMajority of the facility referrals had primary and secondary level of education with those with tertiary and pre-school education and less representing the minority. This is in tandem with study done on injury characteristics in Moshi, Tanzania that revealed majority have primary and secondary level of education (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). This maybe because the facility is a tertiary health facility in an Urban setting in Tanzania, similar to KNH in Kenya. However, it contradicts a study done in rural Tanzania that showed majority of the referrals had no schooling or had primary levels of education (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This could be due to the fact that the study was done amongst antenatal mothers in rural Tanzania where women, who tend to have lower or no education and form the bulk of rural population in Tanzania just like other sub-Saharan African countries.\u003c/p\u003e \u003cp\u003e About half of facility referrals had written referral letters. This contradicts an assessment done on state of health referral system in Kenya in 2013 and in Afghanistan amongst sick children that showed about one-third of referrals had a referral slip (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). However, this study also included the community health units. The study findings also contradict studies done in Kenya, Uganda, Burkina Faso and Nigeria that showed high adherence to the referral guidelines with over two-thirds of facility referrals use formal referral letters (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The comparatively low use of referral letters in the current study could be because most of the referrals were verbal over the telephone and once a verbal consensus had been reached, the referring health facilities did not see the need of writing a formal written referral letter. The study findings also contrast with studies on adherence to referral guidelines and use of referral letters in Cape Town, South Africa, Kenya, Malawi and United States of America that revealed majority adhered to referral guidelines with use of formal referral letters (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49 CR50\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). This is likely due to the fact these health facilities were highly specialized treatment centres for Burn patients. This study revealed that the enforcement of the referral guidelines had no impact on the use of official written referral letters as per national referral guidelines requirements despite increase in the facility referrals resulting from enforcement of national referral guidelines. Its therefore critical that further studies be done to understand the challenges, barriers and obstacles to the use of standard referral forms in patient referrals.\u003c/p\u003e \u003cp\u003e Patients with higher education level were more likely to have written referral letter after enforcement of the referral guidelines. This is in tandem with a study done in Western Kenya on referrals for hypertension that revealed patients with higher education level were likely to receive a referral letter (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). This may be because they are more informed and would need to know the details and why they are referred and appreciate the significance of formal communication to ease access to services at the next level of care.\u003c/p\u003e \u003cp\u003e Females were more likely than men to have a written referral letter after enforcement of the referral guidelines. This maybe because women are known to have better health seeking behavior than men. However, this contradicts a study done in Western Kenya on referrals for hypertension that revealed male patients were likely to receive a referral letter (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). This may be because more older women were admitted after enforcement of the referral guidelines and these women were more-educated, had insurance cover and were therefore more likely to require a formal written referral letter to facilitate smooth referral process to the next level of care.\u003c/p\u003e \u003cp\u003e The use of written referral letters across most of the health facility tiers remained unchanged after enforcement of referral guidelines, patients with from health facilities tier 2 were less likely to have written referral letter after enforcement of the referral letter than tier 3 health facilities referrals. This could be explained by the fact that once the referring health facility have called and informed KNH of the need for referral, they saw no need to follow it up with a written referral letter. This ties in with an evaluation on the state of health referral system in Kenya that revealed that the use of oral referrals comprised about a third of the referrals with the use of the referral form comprising another one-third of the referrals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In addition, tier 2 health facilities were mostly small private clinics and these health facilities in most cases are non-compliant to the government standards and guidelines and are mostly located within the poor settlements in Nairobi and \u0026ldquo;less accessible\u0026rdquo; during the supervisory visits by the county health management staff. Level three health facilities are government and private nursing and maternity homes that are relatively high volume and frequently supervised by the county health management staff and are more likely to be compliant to the government\u0026rsquo;s standards and guidelines.\u003c/p\u003e \u003cp\u003eElective patients were more likely than emergency patients to have a written referral letter. This could be due to the fact that emergency traumatic injuries were done through telephone conversations between the referring health facility and KNH and once an agreement had been reached, the referring health facility found no need to have an official referral letter. This is in tandem with the Kenya referral guidelines stipulates for emergency referrals, the referring health worker communicates directly by phone or any other means of communication available to the receiving health worker to ensure that advance notice of the referral is given to allow adequate preparation (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, this contradicts a study done in Afghanistan amongst sick children that showed use of referral slips by health care providers was higher for urgent referrals (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study had some limitations. First, the effect of COVID 19 pandemic on facility referrals of cases from peripheral health facilities to KNH. This was mitigated by ensuring the data collection period covered the covid period where intercounty movement restrictions were lifted by the Kenyan government. Secondly, this was a retrospective quasi-experimental study design and hence weaker in determining causality. Despite these limitations, given the paucity of published literature in this study topic, this study offers key information on the effects of enforcement of referral guidelines on use of written referral letters in health facility referrals to KNH with important lessons for Kenya and possible sub-Saharan Africa.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe enforcement of the national referral guidelines had no effect on the use of the official written referral letters as per the requirement of the national referral guidelines amongst the orthopedic and trauma admissions at KNH.\u003c/p\u003e \u003cp\u003eMajority of the facility referrals were young and middle-aged men with children and elderly representing the minority. Most of the facility referrals had had primary and secondary level of education with admissions. Women, elective patients and those with higher education were more likely to have a written referral letter.\u003c/p\u003e "},{"header":"Recommendations","content":"\u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFurther studies are needed to understand the obstacles, challenges and barriers towards use of official referral letter;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNeed for an effective referral system monitoring;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNeed for capacity building of health care workers on effective referral process by designing and disseminating referral SOPs and standardized documentation for referrals;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNeed for referral coordinating and review forums \u0026ndash; to review coordination, encourage accountability and continuous improvement and referral performance monitoring;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImproving the capacity and attitude of service providers at all levels of the health system on use of written referral letters;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIntroduce new technology of e-health, such as telemedicine, e-referrals, and e-mail, to improve the referral documentation system.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eCOVID Corona Virus Disease\u003c/p\u003e \u003cp\u003eERC Ethics Review Committee\u003c/p\u003e \u003cp\u003eKNH Kenyatta National Hospital\u003c/p\u003e \u003cp\u003eUoN/KNH University of Nairobi/Kenyatta National Hospital\u003c/p\u003e \u003cp\u003eRA Research Assistant\u003c/p\u003e \u003cp\u003eSPSS Statistical Package for the Social Sciences\u003c/p\u003e \u003cp\u003eSOPs Standard Operating Procedures\u003c/p\u003e \u003cp\u003eUSA United States of America\u003c/p\u003e \u003cp\u003ePCEA Presbyterian Church of East Africa\u003c/p\u003e \u003cp\u003ePI Principal Investigator\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was presented to University of Nairobi/Kenyatta National Hospital (UoN/KNH) Ethics and Research Committee and was granted ethical approval (ERC No: P852/10/2021). Administrative approval was also granted by KNH Medical Research Department and KNH Orthopaedics Department.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interest exists\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was partially funded by Kenyatta National Hospital. RFA 2020/2021. The funders had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author conceptualized, designed, collected data, analyzed and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI would like to sincerely acknowledge the work of Brian Okinyi and Micah J. Kipkemei for commitment and assistance in data collection process.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMoH. The State of the Health Referral System in Kenya: Results from a Baseline Study on the Functionality of the Health Referral System in Eight Counties In: Unit HSMaE, editor. Nairobi, Kenya; 2013.\u003c/li\u003e\n\u003cli\u003eMinistry of Devolution and Planning KM. 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Injury characteristics and their association with clinical complications among emergency care patients in Tanzania. Afr J Emerg Med. 2022 Dec;12(4):378-86.\u003c/li\u003e\n\u003cli\u003eNewbrander W, Ickx P, Werner R, Mujadidi F. Compliance with referral of sick children: a survey in five districts of Afghanistan. BMC Pediatr. 2012 Apr 27; 12:46.\u003c/li\u003e\n\u003cli\u003eNjanwe PJ, Marete I, Ayaya S. Adherence to national healthcare referral guidelines and its effect on the management outcomes among children seen at a Teaching Hospital in western Kenya. East African Medical Journal. 2021;98(1).\u003c/li\u003e\n\u003cli\u003eLal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, et al. Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malar J. 2016 Nov 24;15(1):568.\u003c/li\u003e\n\u003cli\u003eAkande T. Referral system in Nigeria: Study of a tertiary health facility. Annals of African Medicine. 2004;3(3):130 - 3.\u003c/li\u003e\n\u003cli\u003eBoissin C, Hasselberg M, Kronblad E, Kim SM, Wallis L, Rode H, et al. Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children\u0026apos;s Hospital in Cape Town, South Africa. Int J Environ Res Public Health. 2017 Jul 6;14(7).\u003c/li\u003e\n\u003cli\u003ePittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health. 2020 Jul;25(7):824-33.\u003c/li\u003e\n\u003cli\u003eCarter JE, Neff LP, Holmes JHt. Adherence to burn center referral criteria: are patients appropriately being referred? J Burn Care Res. 2010 Jan-Feb;31(1):26-30.\u003c/li\u003e\n\u003cli\u003eAlex M, Olivia CK, Gloria K, Philip B. Referral patterns at a regional faith-based hospital in Western Kenya. International Journal of Advanced Community Practice. 2021;4(4):36-40.\u003c/li\u003e\n\u003cli\u003eThakkar A, Valente T, Andesia J, Njuguna B, Miheso J, Mercer T, et al. Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study. BMC Health Serv Res. 2022 Mar 7;22(1):315.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"referral guidelines, health facility referrals, referral letters, Kenyatta National Hospital","lastPublishedDoi":"10.21203/rs.3.rs-3962350/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3962350/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eInappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low use of formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. This compromises the ability and capacity of Kenyatta National Hospital to function as a referral facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and Kenyatta National Hospital legal statue of 1987. On 1st July 2021, Kenyatta National Hospital (KNH) did enforce the national referral guidelines that required patients have a formal referral letter to reduce the number of self-referrals, decongest KNH and allow KNH to function as a referral facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 2010 constitution and KNH legal statue of 1987. The purpose of this study was to analyse the effect of enforcement of national referral guidelines on use of official facility referral letters to KNH.This was a pre-posttest study design. The study was conducted amongst the orthopedic and trauma facility referrals in 2021 with 222 and 246 before and after enforcement of referral guidelines respectively. Data collection was done through data abstraction. Data was analyzed using frequency distribution, pearson chi-square test and logistic regression. The enforcement of the national referral guidelines had no effect on the use of the official written referral letters as per the requirement of the national referral guidelines amongst the orthopedic and trauma admissions at KNH (p\u0026thinsp;=\u0026thinsp;0.524). Over 80% of facility referrals were young and middle-aged patients before and after enforcement of the referral guidelines with children and elderly representing the minority. Most of the facility referrals had had primary and secondary level of education with admissions. Women, elective patients and those with higher education were more likely to have a written referral letter (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In conclusion, enforcement of the referral guidelines had no effect on use of the official written referral letters to KNH. There is need for capacity building of health care workers on effective referral process by designing and disseminating referral SOPs and standardized documentation for referrals and regular referral review forums to review coordination, encourage accountability and continuous improvement and referral performance monitoring.\u003c/p\u003e","manuscriptTitle":"Does a formal referral system work? Case study of a tertiary teaching and referral hospital in Kenya: Pre-posttest study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 19:28:13","doi":"10.21203/rs.3.rs-3962350/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a1cec98-693c-42a8-9a83-10f1b6e13109","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T14:40:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-06 19:28:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3962350","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3962350","identity":"rs-3962350","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}