Introduction

One of the main strategies to improve access to and the quality and efficiency of healthcare systems is a family physician program (FPP) as the primary care provider within an appropriate referral system. The aim of this study was to investigate the level of adherence of rural insured patients to family physicians (FP) and the referral system, as well as factors that affect self-referral.

Material and methods

This multicenter, cross-sectional study was conducted between April 2018 and February 2019 in East Azerbaijan Province, Iran. A questionnaire-based survey was used to collect data on patient characteristics, adherence to the FPP and referral system, and the reasons for self-referral from 1,553 participants recruited using multistage cluster sampling.

Results

Overall, 58.9% of participants adhered to the FPP and referral system. The total self-referral rate was 41.1%, including 24.3% patients who had attended an FP appointment only to obtain a referral code, and 16.8% had self-referred directly. Data on age, sex, family monthly expenditure, and place of residence were associated with self-referral. Structural pitfalls, societal knowledge and attitudes, and cultural challenges were identified as the patients’ reasons for self-referring. Within these categories, the most frequent reasons included uncertainty about the knowledge and skills of FPs (74.2%), easy and inexpensive access to specialized services (66.7%), better quality of specialized services (59.0%), and a lack of awareness of the FPP and the services provided at level 1.

Conclusions

A significant percentage of enrollees did not adhere to the FPP and referral system. Considering the unwelcome consequences of self-referral, designing and implementing practical interventions seems essential in order to encourage patients to be more compliant.