Out of 10 deaths, 6–8 of them occur in the community before a health facility is accessed(1). Malaria, diarrhea and pneumonia have remained prevalent among children under five years of age and are a leading cause of morbidity and mortality globally.
In Sub-Saharan Africa also contributing to referrals and therefore provision of pre-referred treatment by community health workers (CHWs) (2–4). Sustainable Development Goal 3 target 3.2 emphasized ending all preventable death of children under five by the year 2030(5).
One of the major health challenges has been accessibility of health services. The CHWs have bridged the gap such that over the years with the implementation of integrated community case management (iCCM), accessibility is improving globally (6–9). Several factors contribute to the positive performance of CHWs among which training and supervision stand out universally (10, 11). In sub Saharan African, support supervision staff observe pre-referral records among others particularly motivating the CHWs to be more acceptable by the communities they serve (12).
Through the iCCM approach, there has been a reduction of global cases of childhood malaria, diarrhea and pneumonia significantly and the referral component and completion rates in rural areas settings has also been felt with increasing reliance in the CHW system in many countries (13–15).
Under Uganda’s Ministry of Health iCCM implementation guidelines 2010, the trained CHWs have played a very big role as front liners in managing community cases for many years which has ensured timely treatment of diseases, referral of severe cases and therefore pre-referral care(13). The iCCM strategy has broadly stretched to the hard to reach and underserved rural populations seeking care worldwide (16).
Prior to referral of children under five years of age by CHWs, pre-referral treatment is recommended by World Health Organization (WHO) iCCM guidelines which have been adapted globally identifying five common danger signs namely; convulsions, not being able to drink or breast feed, vomiting, chest in drawing and being very sleepy/ unconsciousness (17, 18).
The additional reasons for referral under iCCM guidelines are cough for 21 days or more, diarrhea for 14 days or more, fever for seven days or more, among the new born children, skin pustules and infected umbilical cord.
A CHW has to provide first dose for some cases and issue a referral form to refer the caregiver to a higher health facility to be managed by professional health workers (19). Some of the cases referred by CHW without providing pre-referral treatment are a negative RDT result, cases CHWs are not mandated to manage under iCCM guideline, children above 5 years of age among others(13).
In a joint statement between WHO/United Nations Children’s Fund on iCCM, they recommends that danger signs are recorded after assessing for malaria, diarrhea and pneumonia while evaluating a sick child. It is at this stage that danger signs are sorted for pre-referral and immediate referral to the nearest health facility (18).
A study in Uganda identified fever with a malaria RDT negative result, drug stock out and danger signs as the common reasons for referral (20). Particularly, the caregiver with a child presenting with danger signs qualifies for pre-referral treatment by a CHW who is trained, supervised and provided with uninterrupted medical supplies.
Pre-referral treatment can be misleading during occasions where caregivers perceived the treatment as final medication to children under-five. In other circumstances, ease of going somewhere else for medical support, lack of time by caregiver, health worker absenteeism and disease severity hindered referrals as were the case in rural Uganda and neighboring countries (21, 22).
In rural Tanzania, a study conducted indicated that much as the CHWs were trained to offer pre-referral medication for severe cases or cases with danger signs, the pre-referral approach was heavily affected by community perceptions (23). Sufficient emphasis on clarification that pre-referral is not complete treatment can strengthen the intention of pre-referral treatment even for less severe cases (24).
Pre-referral treatment is an important part of providing care for childhood illnesses in the community. This study examined the magnitude and predictors of pre-referral treatment in a rural setting. The study findings will contribute to the existing body of knowledge on CHW led iCCM.