Early experiences on the feasibility, acceptability, and use of malaria rapid diagnostic tests at peripheral health centres in Uganda-insights into some barriers and facilitators

Abstract

BackgroundWhile feasibility of new health technologies in well-resourced healthcare settings is extensively documented, it is largely unknown in low-resourced settings. Uganda's decision to deploy and scale up malaria rapid diagnostic tests (mRDTs) in public health facilities and at the community level provides a useful entry point for documenting field experience, acceptance, and predictive variables for technology acceptance and use. These findings are important in informing implementation of new health technologies, plans, and budgets in low-resourced national disease control programmes.MethodsA cross-sectional qualitative descriptive study at 21 health centres in Uganda was undertaken in 2007 to elucidate the barriers and facilitators in the introduction of mRDTs as a new diagnostic technology at lower-level health facilities. Pre-tested interview questionnaires were administered through pre-structured patient exit interviews and semi-structured health worker interviews to gain an understanding of the response to this implementation. A conceptual framework on technology acceptance and use was adapted for this study and used to prepare the questionnaires. Thematic analysis was used to generate themes from the data.ResultsA total of 52 of 57 health workers (92%) reported a belief that a positive mRDT result was true, although only 41 of 57 (64%) believed that treatment with anti-malarials was justified for every positive mRDT case. Of the same health workers, only 49% believed that a negative mRDT result was truly negative. Factors linked to these findings were related to mRDT acceptance and use, including the design and characteristics of the device, availability and quality of mRDT ancillary supplies, health worker capacity to investigate febrile cases testing negative with the device and provide appropriate treatment, availability of effective malaria treatments, reliability of the health commodity supply chain, existing national policy recommendations, individual health worker dynamism, and vitality of supervision.ConclusionsmRDTs were found to be acceptable to and used by the target users, provided clear policy guidelines exist, ancillary tools are easy to use and health supplies beyond the diagnostic tools are met. Based on our results, health workers' needs for comprehensive case management should be met, and specific guidance for managing febrile patients with negative test outcomes should be provided alongside the new health technology. The extent, to which the implementation process of mRDT-led, parasite-based diagnosis accommodates end user beliefs, attitudes, perceptions, and satisfaction, as well as technology learnability and suitability, influences the level of acceptance and use of mRDTs. The effectiveness of the health system in providing the enabling environment and the integration of the diagnostic tool into routine service delivery is critical.

“Even if the test result is negative, they should be able to tell us what is wrong with us”: a qualitative study of patient expectations of rapid diagnostic tests for malaria

“…The highly positive perceptions of RDTs demonstrated by patients in this study correspond closely with other similar studies conducted in Ghana, Tanzania and Uganda [20,21,23-25]. Others have also identified that RDT acceptability is based on its perceived role in aiding the clinician to reach a more definitive diagnosis and prescribe the right treatment for their illness [20,23].…”

“…Others have also identified that RDT acceptability is based on its perceived role in aiding the clinician to reach a more definitive diagnosis and prescribe the right treatment for their illness [20,23]. The value of the test in communicating a patient’s ‘problem’ to the clinician more clearly than they could verbally, has also been reported elsewhere [24].…”

“…Respondents in the study perceived the RDT as able to detect any cause of illness, beyond malaria. This may indicate interpretations of the technology as an ‘object of hope’ in terms of curing illness [30] and may reflect broader ideas that the quality of health care is equated with use of new technologies like RDTs [23], framed by an assumption that problems are resolvable through technological means [31]. …”

“…Patients expected clinicians to use tests and their results alongside clinical expertise to provide appropriate treatment for their diagnosis. This suggests that RDTs did not undermine clinicians’ position and credibility with patients, reported as a fear of clinicians in Uganda [23], but it also suggests that pressure from patients to use RDTs as a primary determinant of anti-malarial usage may be limited in contexts such as this. The finding echoes results from Tanzania where clinician perceptions of patient pressure for anti-malarials were not upheld by patient expectations for the right diagnosis and treatment [33].…”

The development of effective behaviour change interventions to support the use of malaria rapid diagnostic tests by Tanzanian clinicians

“…For example, RDTs also raised conflicts over their own clinical judgement for clinicians in Ghana [12], as was reported previously with microscopy in Tanzania [10]. The narratives employed by health workers in this study to cope with this conflict, which undermined the usefulness, accuracy and relevance of these tests, have also been reported elsewhere, for example in Uganda [58]. Dealing with this conflict posed by RDTs through identifying alternative disease(s) has also been reported in different settings, while simultaneously drawing attention to the lack of support for diagnosing and treating alternative causes across settings with different levels of malaria transmission [12,58-60].…”