Following-up: medical referrals for children in Sudan

When children are taken for medical treatment, they frequently need further treatment to complete their recovery. In Sudan, however, carers often do not act on the health workers’ referrals to hospital or requests for follow-up treatment. There are a number of ways to improve the rate of compliance.

In 1996, the government of Sudan began to implement the World Health Organisation's (WHO) strategy of Integrated Management of Childhood Illness (IMCI) in four districts in 1996. The IMCI strategy requires health workers treating children to classify them according to their symptoms, treat them, and counsel their carers.

A study by the Sudan Ministry of Health, Gezira University, WHO and the London School of Hygiene and Tropical Medicine, classified children according to three categories: those needing urgent referral to hospital; those needing treatment and to return for follow-up treatment some days later; and those needing treatment but no further follow-up.

The researchers examined the extent to which health workers’ recommendations for referrals and follow-up treatment in each of these groups was followed. Of the 1,197 children who required follow-up treatment, only half of the children judged in need of urgent care received that treatment in 24 hours. Mostly, the carers cited cost as the main barrier to this treatment. They also expressed a lack of confidence in the medical care provided by health facilities outside of hospitals, which meant that many went straight to hospital for treatment, bypassing the referral system altogether.

The researchers visited 359 households to determine why only 44.5 percent of carers complied with the follow-up treatment recommended. About 13 percent said they were unaware of the recommendation for follow-up treatment. Of those who were aware, 87 percent said they did not take the child in because the child was better. A small percentage said they had not forgotten about the recommended follow-up treatment, while others said they had not complied because they were not satisfied on the first visit, or that the health workers’ advice was not persuasive.

Furthermore, they found that:

• Where children needed follow-up treatment within two to five days, compliance with the recommendation for this group was much higher than for those children whose recommended follow-up treatment was in 14 or 30 days.
• The level of education of the carer influenced compliance with follow-up treatment – carers who were better educated were more likely to comply.
• Compliance with follow-up treatment increased in instances where children were issued with medicine on their first visit.
• Proximity to health facilities affected compliance in that follow-up was higher where the health facility was located in the child’s village.
• Compliance improved if the child’s carer had a salaried job.

Policy recommendations include:

• As compliance might be reduced by longer periods between the initial and follow-up consultations, the follow-up compliance for children who are underweight and anaemic might be improved if earlier follow-up visits are introduced.
• Increasing the level of education of women in Massalamia would directly benefit the health of the children in their care.
• It is important that health facilities are adequately equipped with essential medicines and that medical staff are made aware of the importance of issuing a first dose of treatment when children visit for treatment.

Compliance would improve if the children’s carers had access to low cost, regular transportation to Medani and Massalamia hospitals, the two hospitals involved in this study. It would also increase if the level of service is improved at Massalamia rural hospital.

Source(s):
‘Integrated Management of Childhood Illnesses strategy: compliance with referral and follow-up recommendations in Gezira State, Sudan’, Bulletin of the World Health Organization 81(10): 708-716, by S.M. al Fadil et al, 2003 Full document.

Funded by: Department of Child and Adolescent Health, WHO

id21 Research Highlight: 20 June 2005

Further Information:
Sumaia Mohammed Al Fadil
WHO Country Office Sudan
PO Box 2234
Sudan

Contact the contributor: sumaiaf@hotmail.com

Gezira University, Sudan

Department of Child and Adolescent Health, World Health Organisation

London School of Hygiene and Tropical Medicine, UK

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