: 2020  |  Volume : 33  |  Issue : 1  |  Page : 25--29

Knowledge and practice of primary health care physicians about referral system in Baghdad

Shaymaa Talal1, Lamia Dhia Aldeen2,  
1 Iraqi Ministry of Health, College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq
2 Department of Family and Community Medicine, College of Medicine, University of Al-Mustansiriyah, Baghdad, Iraq

Correspondence Address:
Lamia Dhia Aldeen
Department of Family and Community Medicine, College of Medicine, Al-Mustansiriyah University, Baghdad


Background: Referral system is one of the key elements in the primary health care (PHC), currently the Ministry of health is working on establishment and development of an effective referral system with incentives to the population to use PHC centers (PHCC) instead of secondary care, this includes monetary incentives and improvement of quality and quantity of services provided at PHC level. Objective: The aim is to assess the knowledge and practice of PHC physicians about the referral system. Methodology: A cross-sectional study with analytic elements was conducted from February 1, 2019 to June 30, 2019, in Baghdad, from both sides AlKarkh and AlRusafa, a convenient sample of 15 PHCC selected., data collection was carried out using a self-administered questionnaire which included questions about demographic characteristics of PHC physicians, qualification, and questions concerning their knowledge and practice about the referral system. Results: Total study group included 150 physicians. Overall knowledge of physicians about the referral system was good, Nearly all physicians (98%) knew its benefit, the results showed that all respondents used referral form (100%), and 94.7% wrote down the required information and followed the classical measures. The referral feedback was poor (36%). Conclusion: Most of the physicians had good knowledge and practice about the referral system. There was strong deficit in the training courses about referral system.

How to cite this article:
Talal S, Aldeen LD. Knowledge and practice of primary health care physicians about referral system in Baghdad.IRAQI J COMMUNITY MED 2020;33:25-29

How to cite this URL:
Talal S, Aldeen LD. Knowledge and practice of primary health care physicians about referral system in Baghdad. IRAQI J COMMUNITY MED [serial online] 2020 [cited 2022 Jan 16 ];33:25-29
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In health care, referral system can be defined as a process in which a health worker at a one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the assistance of a better or differently resourced facility at the same or higher level to assist in, or take over the management of the client's case. Referral can be from lower level of care to higher level for effective management of condition or vice versa, for continuity of care and follow up.[1]

Referral system is referred to as a system because it comprises several parts, among such are: health system issues, initiating facility, referral practicalities, receiving facility, supervision and capacity building, and continuous quality improvement.[2] The reasons of referral either to establish a diagnosis or for treatment, support, and/or for advice. In some cases, the reason to refer is for a routine surgical procedure, or to seek additional services for the client as admission for management.[3]

Effective referral systems between the levels of health-care delivery represent a cornerstone in addressing clients' health needs efficiently and help to ensure people receive the best possible care closest to home. Optimal referring processes are crucial for the effectiveness, safety, and efficiency of medical care.[2],[4]

Ideally, the Primary Health Care Centers (PHCC) are supposed to be the point of first contact of patients from which referral to the secondary and tertiary levels should follow a timely, smooth and organized process.[5] The health services in Iraq are provided through a network of public PHCC and hospitals where services are provided at very low charges.[6]

Objective of the study

To assess the knowledge and practice of primary health care (PHC) physicians about the referral system.


A descriptive, cross-sectional study with analytic element was conducted from February 1, 2019 to June 30, 2019, in Baghdad (AlKarkh and AlRusafa).

A convenient sample of 15 PHCC was selected. Study population includes all physicians working in the selected PHCCs who were available at the time of visit and consented to participate in the study. Data collection was carried out using a self-administered questionnaire (which included questions about demographic characteristics of PHC physicians, qualification, and questions concerning their knowledge and practice about the referral system).

The data were analyzed using the Statistical Package for the Social Sciences version 25 (SPSS version 25 Armonk, NY:IBM corp). Data were presented in tables and figures, simple measures of frequency, percentage, mean, standard deviation, and range (minimum–maximum values).

In order to evaluate the knowledge of studied sample about referral system, scoring method was used and obtained by adding up 1 for the correct answers and 0 for the incorrect, to the investigated variables in the questionnaire. Total number of questions concerning the knowledge about referral was 32, thus the score for knowledge of referral was ranged (0–32), a score <16 considered as poor, scores between (16 and 23) considered as fair and scores ≥24 good. While regarding practice 13 questions were used to determine the practice about referral, where the score of practice ranged (0–13), <7 score was considered as poor, while (7–9) considered as fair, and score of ≥10 was regarded as good.

The significance of association of different percentages (qualitative data) was tested using Pearson Chi-square test. Statistical significance was considered whenever the P ≤ 0.05.


The total number of study participants was 150. The distribution of physicians by demographic characteristics is shown in [Table 1]. Study participants' age was ranging from 26 to 63 years. The highest percentage of studied sample was found in the age group of 30–39 (55.3%). Majority of them were female (76.7%). Concerning qualification, there were 65 physician (43.3%) general practitioners, (40.7%) were family medicine specialists and (16%) were family medicine residents. In terms of duration, the postqualification experience of the physicians ranged from <2 to over 10 years in practice in PHCCs, majority 34% of the participants were (2–4) years and regard having training courses only 9.3% physician had specific courses about referral system at a variable times as shown in [Table 1].{Table 1}

Knowledge about referral system and its definition among physicians are illustrated in [Table 2], as the majority of physicians 86% knew definition of referral. Moreover, 98% knew its benefit, and almost all of them 149 (99.3%) recognized that PHCC is first level of care. Regarding the indication(s) for referral, this study showed that majority of physicians; namely, emergencies (96%) and factors or reasons that are diagnosis oriented and treatment oriented (96.7%, 93.3%), respectively.{Table 2}

Study result revealed good level of knowledge about referral system among participants, where 111 (74%) of physicians had good level and 39 (26%) of them had fair level, none of the physicians had poor level of knowledge about referral system.

[Table 3] illustrates physicians practice about referral system, this study showed that all physicians use referral form (100%), and (94.7%) write down the required information and follow the classical measures. Regarding their reaction to self-requested referral (98.7%) of physicians said that they would explain and try to convince the patient who asked for self-referral to manage their case in PHCC. Concerning feedbacks 36% of physicians claimed that they sometimes receive referral feedback. Regarding records keeping 86% responded that this was the practice in their facility.{Table 3}

Study of practice of referral system by physicians in PHCCs, revealed that 133 (88.7%) of physicians with good practice and only 17 (11.3%) of physicians had fair level of practice. Moreover, none of them had poor level in practice referral system.

[Table 4] shows the relation between demographic characteristics and referral records. it presented that 129 out of 150 participants claimed to keep record in their PHCCs 45% of them were family medicine specialists, 72.8% of them with >2 years of experience. Means higher the qualification and years of experience, more they realize importance of referral records in patient care and follow-up.{Table 4}


The current study showed that majority of physicians had good knowledge about referral system, this is good and encouraging, its comparable with findings by Al-Erian et al. in Saudi Arabia.[7] and other studies in Nigeria and Ghana where participants demonstrated good knowledge about referral system.[2],[8]

The current study showed that all physicians used referral form, and (94.7%) wrote down the required information and followed the required measures in referring patient, in line with other studies, in Saudi Arabia and Egypt[9],[10] also in agreement with a study by the WHO (2008) that showed that the referral letter is the main cornerstone for the referral process and it is the only means of communication between general practitioners and specialists.

Most of physicians 86% claimed that they do keep record of referral systems in their facility. This result is comparable to study from Nigeria[11] where (87.7%) of the respondents saw this practice as necessary, but only 68 (59.6%) responded in the affirmative that this was the practice in their facility.

Concerning recipient of referral feedback, result was comparable to other studies in Saudi, Iran, and Nigeria,[9],[12],[13] where more than half of the participants concurred that they do not normally get feedback from facilities they refer to. The reason for such a low rate of feedback reports, compared with higher rates in some western countries could be the lack of awareness on the part of hospital consultants of the importance of communication with PHCCs in maintaining continuity of care and patient satisfaction[9] and might be due to the lack of referral letters from health workers which have been shown to influence rate of feedback of referred patients.[14]

The current study showed that 17.3% of the participants selected patient request as indication for referral, this result is similar to study by Omole et al., in which 18.1% of the respondents thought that referral should be at the request of patients rather than by the managing physician or health worker. This perspective (even among health workers) may in the long run contribute to the bypassing of lower levels of health care and the resultant increased turnout of self-referrals in tertiary health-care facilities; means overstretching of their services and facilities.[15]


The current work showed that most of the physicians had good knowledge and displayed good practice about the referral system, but the rate of feedback was low. Nearly all physicians ascertain the importance to activate referral system in our country for provision of health care. And recommended that efforts need to made by the various health stakeholders to improve communication among the various levels of health care. Besides, introduction and promotion of structure referral forms and implementation of referral protocols to boost the quality of the referral system in our country.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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