Compliance with referral of sick children: a survey in five districts of Afghanistan

The study was conducted in 5 rural districts of 5 Afghan provinces using interviews with parents or caretakers in 492 randomly selected households with a child from 0 to 2 years old who had been sick within the previous 2 weeks with diarrhea, acute respiratory infection (ARI), or fever. Data collectors from local nongovernmental organizations used a questionnaire to assess compliance with a referral recommendation and identify barriers to compliance.The number of referrals, 99 out of 492 cases, was reasonable. We found a high number of referrals by community health workers (CHWs), especially for ARI. Caretakers were more likely to comply with referral recommendations from community members (relative, friend, CHW, traditional healer) than with recommendations from health workers (at public clinics and hospitals or private clinics and pharmacies). Distance and transportation costs did not create barriers for most families of referred sick children. Although the average cost of transportation in a subsample of 75 cases was relatively high (US$11.28), most families (63%) who went to the referral site walked and hence paid nothing. Most caretakers (75%) complied with referral advice. Use of referral slips by health care providers was higher for urgent referrals, and receiving a referral slip significantly increased caretakers’ compliance with referral.Use of referral slips is important to increase compliance with referral recommendations in rural Afghanistan.Child survival efforts in developing countries focus on applying basic lifesaving interventions to health problems faced by newborns, infants, and young children. These interventions are often applied by mothers or caretakers in the home, first-line health care providers such as community health workers (CHWs), or health care providers at the lowest-level health facility who have been trained to recognize common illnesses and provide basic treatment, such as oral rehydration solution and zinc for diarrhea. The import