Assessment of referrals between primary health centers and CPs and PPMVs for women requiring family planning in Nigeria: A mixed methods study

Abstract Expanding the task-sharing and task-shifting (TSTS) policy to include Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) is essential to increasing access to a broad range of modern contraceptives, as well as building linkages between them and public health facilities. Referrals are important to ensure continuum of care for FP services as CPs and PPMVs have limited scope of services they are authorized to provide. Under the IntegratE Project funded by Gates Foundation, the capacities of CPs and PPMVs were built to provide short-acting contraceptives and implant and are expected to refer clients needing services beyond their capability or scope, to public FP facilities. To inform program implementation, this study assessed the referral practices of CPs and PPMVs when referring FP clients. Main question/hypothesis The objective of the study was to assess the practice of CPs and PPMVs when referring clients for family planning (FP), perception of clients on referrals received, and attitude of primary health care (PHC) providers to referrals from CPs and PPMVs. Specifically, to answer the research question "what are the best ways to facilitate effective referrals"? Methodology The mixed-methods study took place in Kaduna, Lagos, Nasarawa and Kano states in Nigeria from July - August 2024. 524 CPs and PPMVs (28 CPs, and 496 PPMVs) trained by IntegratE project and providing FP services were selected using stratified random sampling and quantitative data collected using structured questionnaires by trained research assistants. This data was analyzed using Stata. Descriptive statistics of demographic characteristics and provider-related factors were conducted. Bivariate analysis using chi-square was used to examine factors associated with FP referral. The qualitative data was collected through in-depth interviews with 37 women who received referrals for FP from CPs and PPMVs across the four states and 20 PHC providers who received referred clients. All interviews were audio-recorded and transcribed verbatim prior to analysis using NVivo 13. Results/key findings Almost one-third (29%) of CPs and PPMVs referred at least a client for FP services in the past 3 months, 65% of these referrals were to primary health centers, and most were done verbally (60%). Results of the bivariate analysis showed that type of provider, gender, state, availability of referral directory, communication between public provider and CPs and PPMVs, providers’ perception of referral facility, and timely attention given to clients at health facility were significantly associated with referrals. PPMVs without health background are most likely to refer women for FP services compared to other providers examined. The qualitative findings showed that the role of CPs and PPMVs in service provision within referral systems is highly recognized by FP clients and public PHC providers. Public FP providers perceived CPs and PPMVs’ practices within the community as important in reducing their workload and contributed to increased awareness about FP services in public healthcare facilities through referral of clients. Clients recognize that referrals are important; they perceived referral as a way of getting better health care. Free FP services at referral sites and prior communication by CP/PPMV were enablers of uptake of referral. A common barrier identified by all participants was that most clients were not given referral slips by CPs and PPMVs. Other barriers to referral are the long distance that clients have to travel, and misconception about referral facilities. Knowledge contribution This study adds to existing knowledge on interventions on referral systems between community actors and public facilities to increase access to modern contraceptives. The results showed that the effectiveness of the referral system depends on the clients, CPs and PPMVs and public sector FP providers. So, interventions to improve referrals for FP services should focus on all providers (public and private) and clients. This study has also demonstrated that gender, state, availability of referral directory, communication between public provider and CPs and PPMVs, providers’ perception of referral facility, and timely attention given to clients at health facility have significant effects on the acceptance and utilization of health referrals. Understanding these factors such as reducing waiting time for clients at public facilities, providing updated referral directory to trained private sector providers, providing referral slips can facilitate referral and enhance clients action to visit public facilities when referred.