Palliative care in aged care facilities for residents with a non‐cancer disease: results of a survey of aged care facilities in South Australia

Objectives: This study reports the results of a cross‐sectional study of residential aged care facilities in South Australia which sought to quantify the extent of specialist palliative care involvement in residential aged care facilities as well as identifying the current need for palliative care. Method: A questionnaire was completed by 51 Directors of Care from 51 of 90 facilities targeted, representing a response rate of 57% and representing 20% of the total number of South Australian licensed beds. Facilities responding were representative of residential aged care facilities in South Australia for location, type of funding and level of care. Results: Thirty facilities (59%) used specialist palliative care services during 2001 with the average number of residents consulted being four. There were 627 deaths recorded in the 2785 licensed beds, a death rate of 23%. The majority of these deaths were from non‐cancer diseases (83%) and up to two‐thirds of all deaths occurred away from low care facilities, usually in an acute care setting. Main reasons for transfer away from the facility were; an acute care episode requiring other expertise, rapid deterioration of the resident, care needs beyond the facility, or the general practitioner or family requested a transfer. Care Directors estimated that 7% of their current residents would be considered palliative and the majority of these had non‐cancer diseases (78%). Conclusion: These findings indicate that palliative care is an important aspect of care in residential aged care facilities for clients with a non‐cancer diagnosis.     

Access to a health facility and care‐seeking for danger signs in children: before and after a community‐based intervention in Lusaka,Zambia

Objective To assess the association of accessibility to a health facility with caregivers’ care‐seeking practices for children with danger signs before and after community‐based intervention in Lusaka, Zambia. Method Health education on childhood danger signs was started in September 2003 at the monthly Growth Monitoring Program Plus (GMP+) service through various channels of health talk and one‐on‐one communication in a peri‐urban area of Lusaka. Two repeated surveys were conducted: in 2003 to collect baseline data before the intervention and in 2006 for 3‐year follow‐up data. Caregivers who had perceived one or more danger signs in their children within 2 months of the surveys were eligible for the analysis. The association between appropriate and timely care‐seeking practices and socio‐demographic and socio‐economic factors, attendance at community‐based intervention and the distance to a health facility was examined with logistic regression analysis. Results The percentage of caregivers immediately seeking care from health professionals increased from 56.1% (106/189) at baseline to 65.8% (148/225) at follow‐up 3 years later (OR = 1.51, P < 0.05). Long distance to the health facility and low‐household income negatively influenced caregivers’ appropriate and timely care‐seeking practices at baseline, but 3 years later, after the implementation of a community‐based intervention, distance and household income were not significantly related to caregivers’ care‐seeking practices. Conclusion Poor accessibility to health facilities was a significant barrier to care‐seeking in a peri‐urban area. However, when caregivers are properly educated about danger signs and appropriate responses through community‐based intervention, this barrier can be overcome through behavioural change in caregivers.     

Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co‐operative Medical System)

Objective To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Methods Data from cross‐sectional household‐based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log‐linear model. Results Between 2002 and 2007, having no any pre‐natal visit decreased from 25% to 12% (difference 13%, 95% CI 10–17%); facility‐based delivery increased from 45% to 80% (difference 35%, 95% CI 29–37%); and differences in using pre‐natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre‐natal and delivery care in 2007. The expenditure for facility‐based delivery increased over the period, but the out‐of‐pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low‐income group. NCMS participation was found positively correlated with lower out‐of‐pocket expenditure for facility‐based delivery (coefficient ?1.14 P < 0.05) in 2007. Conclusions Facility‐based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility‐based delivery, although NCMS participation reduced the out‐of‐pocket expenditure on average.     

Site of care and factors associated with mortality in unvaccinated Australian aged care residents during COVID-19 outbreaks

Background

Residential InReach presents an alternative to hospital admission for aged care residents swabbed for coronavirus disease 2019 (COVID-19), although relative outcomes remain unknown.

Aims

To compare rates and predictors of 28-day mortality for aged care residents seen by InReach with COVID-19, or ‘suspected COVID-19’ (sCOVID), including hospital versus InReach-based care.

Methods

Prospective observational study of consecutive patients referred to a Victorian InReach service meeting COVID-19 testing criteria between April and October 2020 (prevaccine availability). COVID-19 was determined by positive polymerase chain reaction testing on nasopharyngeal swab. sCOVID-19 was defined as meeting symptomatic Victorian Government testing criteria but persistently swab negative.

Results

There were no significant differences in age, sex, Clinical Frailty Score (CFS) or Charlson Comorbidity Index (CCI) between 152 patients with COVID-19 and 118 patients with sCOVID. Similar results were found for 28-day mortality between patients with COVID-19 (35/152, 23%) and sCOVID (32/118, 27%) (P = 0.4). For the combined cohort, 28-day mortality was associated with initial oxygen saturation (P < 0.001), delirium (P < 0.001), hospital transfer for acuity (P = 0.02; but not public health/facility reasons), CFS (P = 0.04), prior ischaemic heart disease (P = 0.01) and dementia (P = 0.02). For patients with COVID-19, 28-day mortality was associated with initial oxygen saturation (P = 0.02), delirium (P < 0.001) and hospital transfer for acuity (P = 0.01), but not public health/facility reasons.

Conclusion

Unvaccinated aged care residents meeting COVID-19 testing criteria seen by InReach during a pandemic experience high mortality rates, including with negative swab result. Residents remaining within-facility (with InReach) experienced similar adjusted mortality odds to residents transferred to hospital for public health/facility-based reasons, and lower than those transferred for clinical acuity.     

Malaria prevalence and treatment of febrile patients at health facilities and medicine retailers in Cameroon

Objective To investigate the quality of malaria case management in Cameroon 5 years after the adoption of artemisinin‐based combination therapy (ACT). Treatment patterns were examined in different types of facility, and the factors associated with being prescribed or receiving an ACT were investigated. Methods A cross‐sectional cluster survey was conducted among individuals of all ages who left public and private health facilities and medicine retailers in Cameroon and who reported seeking treatment for a fever. Prevalence of malaria was determined by rapid diagnostic tests (RDTs) in consenting patients attending the facilities and medicine retailers. Results Among the patients, 73% were prescribed or received an antimalarial, and 51% were prescribed or received an ACT. Treatment provided to patients significantly differed by type of facility: 65% of patients at public facilities, 55% of patients at private facilities and 45% of patients at medicine retailers were prescribed or received an ACT (P = 0.023). The odds of a febrile patient being prescribed or receiving an ACT were significantly higher for patients who asked for an ACT (OR = 24.1, P < 0.001), were examined by the health worker (OR = 1.88, P = 0.021), had not previously sought an antimalarial for the illness (OR = 2.29, P = 0.001) and sought treatment at a public (OR = 3.55) or private facility (OR = 1.99, P = 0.003). Malaria was confirmed in 29% of patients and 70% of patients with a negative result were prescribed or received an antimalarial. Conclusions Malaria case management could be improved. Symptomatic diagnosis is inefficient because two‐thirds of febrile patients do not have malaria. Government plans to extend malaria testing should promote rational use of ACT; though, the introduction of rapid diagnostic testing needs to be accompanied by updated clinical guidelines that provide clear guidance for the treatment of patients with negative test results.     

Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana

Objectives To assess whether supervision of primary health care workers improves their productivity in four districts of Northern Ghana. Methods We conducted a time‐use study during which the activities of health workers were repeatedly observed and classified. Classification included four categories: direct patient care; documentation and reporting; staff development and facility operations; and personal time. These data were supplemented by a survey of health workers during which patterns of supervision were assessed. We used logistic regression models with health facility fixed effects to test the hypothesis that supervision increases the amount of time spent providing direct patient care (productivity). We further investigated whether these effects depend on whether or not supervision is supportive. Results Direct patient care accounted for <25% of observations. In bivariate analyses, productivity was higher among midwives and in facilities with a high volume of care. Supervisory visits were frequent in those four districts, but only a minority of health workers felt supported by their supervisors. Having been supervised within the last month was associated with a significantly higher proportion of time spent on direct patient care (OR = 1.57). The effects of supervision on productivity further depended on whether the health workers felt supported by their supervisors. Conclusion Supportive supervision was associated with increased productivity. Investments in supervision could help maximize the output of scarce human resources in primary health care facilities. Time‐use studies represent an objective approach in monitoring the productivity of health workers and evaluating the impact of health‐system interventions on human resources.     

Factors associated with death places among elderly patients receiving home-based care

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care.This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors.The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37–7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12–25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03–0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03–0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13–0.90; P = .030).Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.     

Access to pediatric subspecialty care: a population study of pediatric rheumatology inpatients in California

Objective

To examine trends in the specialty care hospitalization of pediatric rheumatology patients and determine how nonclinical factors influence access.

Methods

This study used California's Office of Statewide Health Planning and Development discharge database to perform a retrospective population analysis of pediatric rheumatology hospitalizations in California between 1999 and 2007. We used logistic regression to examine the relationship between hospitalization in specialty care centers with a pediatric rheumatologist and nonclinical patient characteristics.

Results

A total of 18,641 pediatric discharges revealed that 57% were discharged from a specialty care center with a pediatric rheumatologist. Multivariate analysis showed that the factors associated with increased utilization of specialty care centers with a pediatric rheumatologist were public insurance (odds ratio [OR] 1.62, 95% confidence interval [95% CI] 1.51–1.74; P < 0.0001), being Hispanic (OR 1.29, 95% CI 1.19–1.40; P < 0.0001) or Asian non‐Hispanic (OR 1.39, 95% CI 1.26–1.54; P < 0.0001), and high pediatric rheumatology specialty care bed supply (OR 2.79, 95% CI 2.49–3.14; P < 0.0001). A decreased utilization of specialty care centers with a pediatric rheumatologist was seen for patients ages <1 year (OR 0.45, 95% CI 0.40–0.52; P < 0.0001), ages 1–4 years (OR 0.50, 95% CI 0.46–0.55; P < 0.0001), ages 5–9 years (OR 0.68, 95% CI 0.62–0.75; P < 0.0001), ages 15–18 years (OR 0.51, 95% CI 0.47–0.56; P < 0.0001), males (OR 0.75, 95% CI 0.70–0.80; P < 0.0001), and patients residing farther away from a specialty care center with a pediatric rheumatologist (OR 0.57, 95% CI 0.51–0.63; P < 0.0001).

Conclusion

Nonclinical factors play an increasingly important role in the hospitalization patterns of pediatric rheumatology patients in California. Understanding these factors is crucial if we are to ensure that the variation in access to care reflects clinical need.     

Current admission policies of long-term care facilities in Japan

Background:   The rapidly aging society in Japan is putting demands on long-term care facilities for the elderly who require care. In Europe and the USA, there is ongoing reform of elderly care services, but the establishment of system based on social insurance is still being explored in Japan.
Methods:   Two studies were conducted, the first in 2000 and the second in 2001, involving 91 long-term care facilities located in or around the city of Nagoya. Questionnaires were sent to facility directors, chief administrators or head nurses to inquire about their admission policies for six major patient categories. Two educational lectures on methicillin-resistant Staphylococcus aureus (MRSA) and urinary incontinence were given between the distribution of the questionnaires.
Results:   For all six categories featured on the questionnaire, the acceptance rate in both studies was the highest in geriatric hospitals, and an improvement in acceptance rates was seen in the second study in all three types of care facilities. When the effect the lectures had on changes in admission policies at these facilities was examined, no correlation was found.
Conclusions:   Lectures should be given to facility management and personnel to raise their awareness of key issues and improve their efficiency.     

Improving Transitions to Postacute Care for Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care Transitions

Purpose

Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.

Emergency room visit: a red‐flag indicator for poor diabetes care

Aim To determine the association between emergency room (ER) admission and quality of diabetes care in the community. Methods In a nested case–control study of patients with Type 2 diabetes mellitus (DM) within a large health maintenance organization (HMO) in Israel, 919 patients who were admitted to one of West Jerusalem’s ERs between 1 May and 30 June 2004 were compared with 1952 control subjects not admitted. Data on study covariates were retrieved from the HMO’s computerized database and a subset of the study population was interviewed. Logistic regressions were conducted to estimate the odds ratios of being admitted according to different measures of quality of care, controlling for socio‐demographic variables, co‐morbidities and type of DM treatment. Results The main indices of quality of primary care that were inversely associated with visiting an ER during the study period included performance of a cholesterol test in the year prior to the index date [adjusted odds ratio (OR) 0.23, 95% confidence interval (CI) 0.19–0.29, P < 0.001], performance of glycated haemoglobin test (OR 0.26, 95% CI 0.24–0.29, P < 0.001), visiting an ophthalmologist (OR 0.47, 95% CI 0.32–0.68, P = 0.001), and recommendations to stop smoking (OR 0.10, 95% CI 0.05–0.21, P < 0.001). Conclusions Admission to the ER can be used as an indicator for poor quality of diabetes care. There is an association between ER admission and poor quality of diabetes care.     

Adherence to a multifactorial fall prevention program following paramedic care: Predictors and impact on falls and health service use. Results from an RCT a priori subgroup analysis

Objective

To identify predictors and impact of adherence to a multifactorial fall‐prevention program on falls and health service utilisation.

Methods

Randomised controlled trial with a priori subgroup analysis within intervention group according to adherence. Participants were community dwelling, (≥65 years), not transported to hospital following fall‐related paramedic care. The Attitudes to Falls‐Related Interventions Scale (AFRIS) was completed at baseline, adherence levels were measured (three‐point scale) at six months, and falls and health service utilisation were recorded for 12 months. Multivariate logistic regression and area under the curve were calculated with 95% confidence interval (CI).

Results

Attitudes to Falls‐Related Interventions Scale scores (n = 85) were independent of baseline characteristics. At six months, 39 (46%) participants reported full adherence. Independent predictors of adherence were positive AFRIS (OR 4.10, 95% CI 1.48–11.39) and receiving 3+ recommendations (OR 3.36, 95% CI 1.26–9.00). Adherers experienced fewer falls (IRR 0.53, 95% CI 0.45–0.80) and fall‐related health service use (emergency department presentations IRR 0.37, 95% CI 0.17–0.82) compared to non‐adherers.

Conclusion

Older adults who adhere to recommendations benefit, regardless of fall‐risk profile.     

Language needs and service provision for older persons from culturally and linguistically diverse backgrounds in south‐east Melbourne residential care facilities

Objectives: To provide up‐to‐date figures on the language needs of older persons from culturally and linguistically diverse (CALD) backgrounds in local residential care facilities and to investigate the extent to which these needs are catered for by the provision of language‐relevant services. Methods: A postal questionnaire was sent to 189 registered aged care facilities in the south‐east region of Melbourne, Victoria. The questionnaire focused on three main issues: the number of residents who preferred or needed to speak non‐English languages; the staff available to speak to residents in non‐English languages; and the language‐specific services provided at their facility. Results: As many as 19% (1191/6409) of residents either preferred or needed to speak one of 40 different non‐English languages. While over half of the facilities had at least one staff member who conversed with residents in their preferred language, residents speaking nine non‐English languages were never spoken to in their original tongue. Almost one‐quarter of the facilities did not provide any language‐relevant services. Conclusion: The findings emphasise the need for widespread use of language‐appropriate services and, due to the growing ageing migrant population, have important policy implications.     

Treatment preferences among depressed primary care patients

OBJECTIVE: To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients. DESIGN: Patient questionnaires and interviews. SETTING: Forty-six primary care clinics in 7 geographic regions of the United States. PARTICIPANTS: One thousand one hundred eighty-seven English-and Spanish-speaking primary care patients with current depressive symptoms. MEASUREMENTS AND MAIN RESULTS: Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P=.001) and had greater knowledge about antidepressant medication (OR, 2.6; 95% CI, 1.6 to 4.4; P≤.001) than those who did not want treatment. A majority (67%, n=660) of those preferring treatment preferred counseling, with African Americans (OR, 2.2; 95% CI, 1.0 to 4.8, P=.04 compared to whites) and those with greater knowledge about counseling (OR, 2.1; 95% CI, 1.6 to 2.7, P≤.001) more likely to choose counseling. Three hundred twelve (47%) of the 660 desiring counseling preferred group over individual counseling. Depression severity was only a predictor of preference among those already in treatment. CONCLUSIONS: Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments. Salary support for Dr. Dwight-Johnson from NIMH grant K 12 MH00990-01-01, Partners in Care study funded by Agency for Health Care Policy and Research grant HS08349-02.     

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa

Objective To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa. Methods Participants were sick children 2–59 months old presenting for care at PHC clinics in KwaZulu‐Natal (KZN) and Limpopo provinces from 2006–2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV. Results A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9–5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05). Conclusions Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence‐based guidelines, implementation must be improved to achieve adequate coverage of life‐saving interventions.     

Emergency obstetric care availability: a critical assessment of the current indicator

Monitoring progress in reducing maternal and perinatal mortality requires suitable indicators. The density of emergency obstetric care (EmOC) facilities has been proposed as a potentially useful indicator, but different UN documents make inconsistent recommendations, and its current formulation is not associated with maternal mortality. We compiled recently published indicator benchmarks and distinguished three sources of inconsistency: (i) use of different denominator metrics (per birth and per population), (ii) different assumptions on need for EmOC and for EmOC facilities and (iii) failure to specify facility capacity (birth load). The UN guidelines and handbook require fewer EmOC facilities than the World Health Report 2005 and do not specify capacity for deliveries or staffing levels. We recommend (i) always using births as the denominator for EmOC facility density, (ii) clearly stating assumptions on the proportion of deliveries needing basic and comprehensive emergency obstetric care and the desired proportion of deliveries in EmOC facilities and (iii) specifying facility capacity and staffing and adapting benchmarks for settings with different population density to ensure geographical accessibility.     

Opinions, knowledge, and self-reported practices related to infection control among nursing personnel in long-term care settings

Background: Because educational needs of staff in long-term care facilities regarding infection control have, not been well studied, we conducted this study to measure long-term care staff members' knowledge, self-reported practices, and opinions about infection control and handwashing.Methods: A pilot study was conducted with 24 staff members of one long-term care facility to examine psychometric properties of study instruments. All nursing staff members (n = 105) from two additional long-term care facilities then completed a 14-item knowledge questionnaire, 22-item opinion survey, and 26-item survey of self-reported handwashing practices.Results: Respondents were predominantly female with mean age of 46 years; most had completed high school. Mean length of employment in the study facility was 12.4 years. Registered nurses and licensed practical nurses scored significantly higher on knowledge (p = 0.0002) but significantly lower on self-reported practices (p = 0.01) than did trained nursing assistants. There was no significant correlation between self-reported practices and opinions regarding handwashing (p = 0.55). Neither level of knowledge nor positive opinion about the value of handwashing was associated with self-reported increases in handwashing practices.Conclusion: We conclude that education alone is not likely to be associated with changes in handwashing behavior. Instruments developed and tested in this study can be used in further research to correlate self-reported with observed behavior and to evaluate the effects of interventions on knowledge, opinions, and self-reported handwashing behavior.     

Factors influencing adherence to referral advice following pre-referral treatment with artesunate suppositories in children in rural Tanzania

Objective WHO recommends artemisinin suppository formulations as pre‐referral treatment for children who are unable to take oral medication and cannot rapidly reach a facility for parenteral treatment. We investigated factors influencing caretakers’ adherence to referral advice following pre‐referral treatment of their children with rectal artesunate suppositories. Methods The study was nested within an intervention study that involved pre‐referral treatment of all children who came to a community dispenser for treatment because they were unable to take oral medications because of repeated vomiting, lethargy, convulsions or altered consciousness. All patients who did not comply with referral advice were stratified by actions taken post‐referral: taking their children to a drug shop, a traditional healer, or not seeking further treatment, and added to a random selection of patients who complied with referral advice. Caretakers of the children were interviewed about their socio‐economic status (SES), knowledge about malaria, referral advice given and actions they took following pre‐referral treatment. Interview data for 587 caretakers were matched with symptoms of the children, the time of treatment, arrival at a health facility or other actions taken post–pre‐referral treatment. Results The majority (93.5%) of caretakers reported being given referral advice by the community drug dispenser. The odds of adherence with this advice were three times greater for children with altered consciousness and/or convulsions than for children with other symptoms [odds ratio (OR) 3.47, 95% confidence interval (CI) 2.32–5.17, P < 0.001]. When questioned, caretakers who remembered when (OR 2.19, 95% CI 1.48–3.23, P < 0.001) and why (OR 1.77, 95% CI 1.07–2.95, P = 0.026) they were advised to proceed to health facility – were more likely to follow referral advice. Cost did not influence adherence except within a catchment area of facilities that charged for services. In these areas, costs deterred adherence by four to five times for those who had previously paid for laboratory services (OR = 0.25, 95% CI: 0.09–0.67, P = 0.006) or consultation (OR 0.20, 95% CI: 0.06–0.61, P = 0.005) compared with those who had not. Conclusion When given referral advice, caretakers of patients with life‐threatening symptoms adhere to referral advice more readily than other caretakers. Health service charges deter adherence.