• Effects Of Referral Leakage On Dmg Download
• Effects Of Referral Leakage On Dmg File
• Effects Of Referral Leakage On Dmg Software

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Abstract

Introduction: Health care delivery systems in rural areasface numerous challenges in meeting the community's needs. This study aimed to describebarriers of health care process in rural societies in Iran.

Methods: In this qualitative study, 26 participants (21rural health care providers and five rural patients) were selected through purposivesampling. The data was collected via semi-structured individual interviews and small focusgroup discussions. Data was analyzed with qualitative content analysis.

Results: One category, “ineffective referral system”, andfive subcategories, i.e. being far from the ideal referral system, lack of adequategovernmental referral system, lack of connection between different levels of the referralsystem, self-referential and bypassing the referral system, and insufficient knowledgeabout the referral system, were found.

Conclusion: Considering the obstacles to the referralsystem, improvements in its structure are necessary to promote the quality of health carein rural areas. Such changes require coordination between the three levels of the referralsystem, strengthening the public sector of the system, increasing public awareness aboutthe referral system, and prevention of self-referential.

Effects Of Referral Leakage On Dmg Download

Introduction

Rural health and its care provision have been major concerns and international discussionsin recent years.¹ About half of theseven-billion world population lives in rural areas. As this large population requiressubstantial health services, their health attracts the attention of nurses, midwives, andother health care providers as well as health care systems and governments. All people deserve to have access to healthcare services regardless of their place of residence and rural populations are noexception.³ Nevertheless, ruralcommunities are still experiencing a multitude of health problems in comparison with theirurban counterparts.^3,

Primary health care is commonly used as the main strategy to satisfy the health needs ofrural areas across the world.Although theconcept of primary health care, as a strategy to bring health for all, has remainedlasting,there is little equality in its implementation. In fact, many primary health careprograms in low-income countries have been unsuccessful due to their lack of necessaryadequacy.

According to the census of 2011, Iran has a population of over 70 million among whom 29%live in rural areas.^6, After the Islamic Revolution in Iran, the priority ofrural and underserved areas was been stated as a basic policy. Primary health care system ofIran was hence located in both rural and urban areas to improve health care fordisadvantaged people and to reduce the gap between health outcomes. In the past two decades,health indicators in Iran have undoubtedly had significant improvements due to theimplementation of the primary health care program.⁸However, the health care delivery system in rural areas is still facingnumerous challenges in dealing with the needs of the society.

Health care services in rural areas of Iran are provided through an extensive nationalnetwork consisting of a referral system. It begins from primary care centers in the area andcontinues up to secondary and tertiary levels in the higher centers.¹⁰ The referral system in all environments of primaryhealth care (PHC) ensures equitable possibility of access to secondary and tertiary healthcare by all members of the community.^11-13 Implementation of the referral system isconsidered as one of the strengths of the Iranian health care system.¹⁴ The way of implementation of referral system hasinfluence on quality of health care process in rural areas. Despite the belief about theabsolute efficacy of the referral system, it always has to cope with variouschallenges.^12,13Quantitative studies have shown that the referral systemhas low effectiveness and efficiency and will thus need to be improved in terms ofperformance.^13,15

While the referral system is one of the major challenges of the health system in thefuture,¹⁶ no qualitative study hasevaluated the barriers to the referral system in the process of health care provision inrural areas. Considering social and cultural complexities, it is impossible to understandhealth care and its barriers within the paradigm of proof-oriented and most scientific andexperimental approaches. Since care is a phenomenon depending on the surrounding socialcontext,¹⁷ the best way to understandit is assessments in its natural environment. Such a view of nature-oriented approach orinterpretation attempts to study the phenomena and processes in their natural, compatibleenvironment. Today, qualitative research methods play an important role in our understandingof rural health issues. The qualitative research methods are identified as appropriatemethods for research on rural health and other areas of social research. Qualitative methodshave the necessary capacity to produce data to discover the effects of social context onhealth.¹⁸ These approaches in thestudy of primary health care are necessary when a researcher wants to focus on theexperiences of the participants.¹⁹Considering disability of proof-oriented or quantitative paradigm in understanding of thehealth care process and its barriers in terms of cultural and social complexity, in thisstudy, the researcher, who had worked as a coach in rural health centers for 11 years, triedto describe people and health care providers’ experiences about the barriers to health careprocess in rural community.

Materials and Methods

This qualitative content analysis was performed to describe barriers to care process inrural communities of Iran during 2011-12. Rural region of Arsanjan (a city in Fars Province)was the research environment. A total of 26 participants including 21 rural health careproviders (13 health workers, two rural family physicians, two midwives, and four ruralnurses) and five villagers were selected by purposive sampling. The inclusion criteria werehaving at least two years of experience in the field of health care in rural areas andwillingness to describe personal experiences. The majority of participants in this studywere health workers who had a significant role in the process of health care provision inrural areas. The experiences of other participants in the health care process was used tofurther clarify the process of health care in rural areas in the form of theoreticalsampling.

Data was collected by semi-structured interviews and small focus group discussions.Interviews were performed in rural health centers, health homes, and the participants’houses. The interview questions were about the process of health care in rural areas. Eachinterview was analyzed and rewritten before the next interview. The average interview timewas 60 minutes and interviews continued until data saturation. Small focus group interviewswith a total of three to four participants with specialized knowledge or experience in thediscussion topic are one of the best methods to collect qualitative data.²⁰ We held a meeting with four nurses who hadworked in rural health care centers (second level referral system) and obtained their viewson the process of health care in rural areas. The small group discussions concerned thechallenges in rural health care. We recorded the participants' interactions as a dataresource; in addition, the researcher also acted as facilitators during the groupdiscussion.

Before the initiation of the study, the subjects were explained about the study protocoland aims, their right to withdraw at any time, and also the anonymity and confidentiality ofdata. They were then asked to sign written informed consent forms. The interviews wererecorded only if the interviewee accepted to. Time and place of interviews were selectedbased on the participants’ ideas.

Data was analyzed using qualitative content analysis according to the method described byGranheme and Landman.^, This process includes open coding, abstracting, andcreating classes. All individual and group interviews were transcribed and the texts wereread several times. Then, initial codes (semantic units) were determined. During the processof open coding, the researcher examined texts line by line and word by word. By allowing thefree creation of the codes, all aspects of the content were described in respondents’ words.In the next step, semantically similar codes were allocated to the same class. The classeswere then grouped to form larger classes to make the minimum number of groups. Microsoftoffice onenote 2007 was used to assist data analysis.

Various methods were used to ensure the accuracy of the study. After the coding, theparticipants were asked to confirm the accuracy of the codes and interpretations. To ensureconsistency in data analysis, during the interview coding, the researcher was referring toprevious coding interviews to evaluate codes again. The researcher also asked facultymembers, faculty advisors, and colleagues familiar with qualitative research for theircomments about the correctness of the processes of analysis and interpretation. In order toincorporate the production resources and methods of data collection, the researcher tried tochoose subjects from all groups related to caring process in the rural areas and also useddifferent methods such as interviews and group discussions to collect data.

Results

The participants in this study were 21 health team members and five rural clients.Demographic characteristics of the subjects are presented in table 1. A main class, “The referral system is dysfunctional”, was emerged. Itincluded subcategories of being far from the ideal referral system, lack of adequategovernmental referral system, lack of connection between different levels of the referralsystem, self-referential and bypassing the referral system, and insufficient knowledge aboutthe referral system.

Table 1

The referral system is far from the ideal state

Our findings indicate that although the referral system is good but it has not been wellimplemented. Nurses participating in group discussion believed that 'a referral system isgenerally good and will work fine if implemented correctly. But unfortunately, it does notrun well”. A family physician stated that the referral system has many problems, e.g.patient care is not practiced as it should be and patient does not receive the servicesthey need. A midwife declared that the referral patterns are wrong and that the routineshould be visiting a general physician first and be referred to a specialist only ifnecessary. Based on the experiences of health caregivers and the current situation, thereferral system is a preventing factor against the rural health care process.

Lack of adequate governmental referral system

According to the participants, the governmental referral system is not responsive to theneeds of rural communities, i.e. the number of experts and their attendance days inclinics is limited. A health worker stated that the governmental health clinic is crowded,especially public clinics that are only two days a week, all people want to go to publicclinics, but we're 23 health centers. Moreover, the patients are obliged to wait long fortheir turn or to a private office.

'We can say there are no governmental specialists because they are too few. They onlyvisit 10-15 patients two days a week', said a health care provider. The governmentalreferral system failure has led the patient to leave it in many cases.

Lack of connection between different levels of the referral system

The participants emphasized the absence of necessary connections in the hierarchy of thereferral system. The process of referral and patient follow up may be disturbed by lack offeedback on the referral system or when the patients leave the governmental referralsystem.

'We are not given feedback. Whenever we refer patients to doctors, we ask them to writeus about what they have done. But they will only sign and seal the referral form',complained a health worker.

'We refer patients to doctors with a referral form. It is our duty to send referralforms but no doctor sends us feedback', mentioned another health worker. Lack of feedbackfrom higher to lower levels has been one of the preventing factors in the referral systemand affected the quality of health care in rural areas.

Self-referential or bypassing the referral system

Non-compliance with the hierarchy of the referral system and referring directly to thephysicians and more specialized levels as self-referral were other problems in ruralhealth care provision. A health worker reported that people do not follow the referralsystem and that they directly refer to specialists.

People, on the other hand, are dissatisfied with their obligation to refer to healthcenters for using their rural insurance. The necessity of attending the referral scheme isnot pleasant for people especially in emergency situations. Sometimes, the problem is theabsence of the family physician.

'I do not have rural insurance, but those who do are in real trouble. They go to a ruralhealth center taking referral form with seals and go. The doctor writes prescribed drugson one page and tests on the next page, but the next page is no longer valid. People areannoyed because no physician in the emergency room would sign the referral form..',stated a villager.

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'The problem is that if a physician is on leave and you want to make an urgentreference, the costs are not covered by the rural insurance because the insurance sheetshould be stamped by physicians. Family physicians are usually absent during non-officehours', said a health worker. Therefore, people will go directly to a specialist. In groupdiscussion, nurses concluded that patients recognize that they should go to a specialist.Self-referential and bypassing the referral system were hence the factors that affectedthe quality of health care.

Insufficient knowledge about the referral system

Based on the statement of the participants, many people and staff members do not fullyknow and understand the referral system and this causes problems in the health careprocess.

'Family physicians and referral system are for people’s convenience. But some people donot have this level of understanding and awareness', mentioned a health worker. Not onlypeople, but also health care providers lack adequate knowledge in this regard. Thisunawareness is an obstacle to the referral system and influences the quality of healthcare in rural areas.

Discussion

Results of this study indicated that the referral system in rural areas is far from itsideal state. In fact, the referral system is not being implemented as it has been defined.Similarly, Ebadi Farde Azar believed that the referral system is still much different fromits ideal state. Admission without referral forms is common and approximately there is noreference among patients with referral forms and without referral forms.²³ Likewise, Nasrollahpour Shiravani et al. showed thatmany of the referral system rules are not respected, i.e. patients are not referred tofamily physicians by health homes or to the second level according to the diagnosis of thefamily physician, taking the role of selecting level 2 physicians by family physicians,higher levels do not provide feedback to the lower levels, following the referred case byhealth workers and family physicians, and patients are not returned to the firstlevel.^12,13 An ideal referral system will require sufficient coordination andrelationships between its different levels and elements. In such a system, reference to thehigher level will only be possible through the lower level and referred cases can hence betracked by receiving feedback from higher levels

We also found that the governmental referral system is not responsive to the needs ofrural communities. In addition, the number of specialists and the time of their presence inrural health centers is limited. Overcrowding generally forces patients to wait for a longtime or to go to the private office of a specialist. Referral system is designed to optimalthe use of three levels of health services and to avoid unnecessary congestion and waste ofhuman and material resources in the specialized levels.^11, However, limitations inspecialty levels and overload of non-urgent referred cases have made the referral systemunsuccessful.

The findings of this study indicated the absence of necessary connections in the hierarchyof the referral system. Lack of feedback in the referral system or the patients’ tendency toleave the governmental referral system disturbs the process of referral and patientfollow-up. Results of this study were consistent with other studies. For instance, Khayyatiet al. showed that rate of feedback received by family physicians from higher centers was36%. They suggested that since feedback is very important to the management and treatment ofpatients in family physician program, all referred cases should receive feedback. Thus, thisrate of feedback is not acceptable.Nasrollahpour Shiravani et al. found absent or poor feedback as a common problem in thereferral system that most of the grading care systems are faced with. However, inwell-organized health systems, higher levels should record outcome of visit and treatment ofall referred patients from the lower level in standard form and should report the follow-uprecommendations to the referring center.^12,13 Ebadi Farde Azar study also showed that thereis no favorable situation in terms of feedback and no kind of feedback is given to patintswith referral leaves (or without referral leaves).²³

According to the findings of this study, self-referential, bypassing the referral system,not following the hierarchy of the referral system, and going directly to the physician andmore specialized levels are other problems in the process of care in rural areas. People’sobligation to respect the hierarchy of the referral system, especially in cases ofemergency, is a major factor in their dissatisfaction. They are dissatisfied because theycan only use rural insurance in health homes or for visiting their family physician.Similarly, Nasrollahpour Shiravani et al. showed that more than half of the patients weredirectly referred to the second level by family physicians without a referral from healthhomes. They also found inadequate compliance with the referral rules is not only bypassingthe health house, some patients were referred based on their request and insistence.Unnecessary referral of patients to the second level is one of the challenges ofhierarchical systems of care including the family physician program and referral system. Inthe absence of appropriate control measures, concerns about the effectiveness of the plan inpreventing undue and unnecessary referral of patients to the second level willincrease.^12,13 Previous studies have introduced referral systems as a strategy to makebetter use of hospitals and tertiary health care services. However, all patients shouldfirst be seen by a primary health care physician who decides on the necessity of thereferral. Access to hospital care should be through primary health care centers except foremergency cases. This prevents the inefficiency of a system and lack of specialty care dueto increased pressure on specialists following inappropriate self-referential. Despite areference structure, there are many situations in which people try to escape from primarycare. Unnecessary self-referential results in ineffective specialized system and problemssuch as increased unnecessary costs, payment difficulties for patients, absence ofcomprehensive care information for patients, lack of planned referral and continuity incare, reduced specialty care standards due to increased system load, reduction in thefeedback and follow-up care instructions, and transportation problems for both individualsand the health care system.^11,

Our findings indicated staff members and patients’ lack of awareness about the referralsystem and the probable problems caused by bypassing it. Consistent with our finding,Nasrollahpour Shiravani et al. showed that a small number of patients returned to the firstlevel or their referring doctors after receiving care at the second level. The majority ofpatients cited lack of knowledge as the main reason.^12,13 Likewise, Shams et al. showedthat knowledge on health services provision at the primary level in the referral systemaffects the refer rate and people acceptance of these services. Hence, investment inupgrading this factor can ensure the usefulness of the system.¹⁵

Overall, the results of the present study suggested the quality of the referral system asan important factor in undesirable process of health care in rural areas. Barriersassociated with the referral system are inhibiting factors of the health care process inrural areas and can influence the quality of care process and inhibit the referral systemfrom achieving the desired goals.

Although the present study provided valuable points about the barriers caused by thereferral system to the process of health care in rural communities, the findings should begeneralized with caution due to the subjective nature of the collected data and the smallnumber of participants. Since this study was part of a wider study aimed to explaining theprocess of health care in rural areas, further studies are recommended to specificallydetermine the challenges of the referral system in rural areas.

Conclusion

The quality of the referral system is undoubtedly one of the main factors in determiningthe health care process in villages. Obstacles to high-quality implemen- tation of thereferral system can prevent the achievement of its goals. Since the current conditions ofthe referral system are not desirable, the structures of the referral systems have to beimproved by creating greater coordination between the three levels of the referral system,strengthening public sector of the system, increasing public awareness and the knowledge ofcaregivers about the system, and preventing self-referential.

Acknowledgments

Author would like to acknowledge all the patiens participated in this research. We alsoacknowledge the Kerman university of medical sciences for funding this research.

Ethical issues

None to be declared.

The authors declare no conflict of interest in this study.

Conflict of Interest

The authors declare no conflict of interest in this study.

References

Effects Of Referral Leakage On Dmg File

Effects Of Referral Leakage On Dmg Software