Guidelines and mindlines: why do clinical staff over-diagnose malaria in Tanzania? A qualitative study

Abstract

BackgroundMalaria over-diagnosis in Africa is widespread and costly both financially and in terms of morbidity and mortality from missed diagnoses. An understanding of the reasons behind malaria over-diagnosis is urgently needed to inform strategies for better targeting of antimalarials.MethodsIn an ethnographic study of clinical practice in two hospitals in Tanzania, 2,082 patient consultations with 34 clinicians were observed over a period of three months at each hospital. All clinicians were also interviewed individually as well as being observed during routine working activities with colleagues. Interviews with five tutors and 10 clinical officer students at a nearby clinical officer training college were subsequently conducted.ResultsFour, primarily social, spheres of influence on malaria over-diagnosis were identified. Firstly, the influence of initial training within a context where the importance of malaria is strongly promoted. Secondly, the influence of peers, conforming to perceived expectations from colleagues. Thirdly, pressure to conform with perceived patient preferences. Lastly, quality of diagnostic support, involving resource management, motivation and supervision. Rather than following national guidelines for the diagnosis of febrile illness, clinician behaviour appeared to follow 'mindlines': shared rationales constructed from these different spheres of influence. Three mindlines were identified in this setting: malaria is easier to diagnose than alternative diseases; malaria is a more acceptable diagnosis; and missing malaria is indefensible. These mindlines were apparent during the training stages as well as throughout clinical careers.ConclusionClinicians were found to follow mindlines as well as or rather than guidelines, which incorporated multiple social influences operating in the immediate and the wider context of decision making. Interventions to move mindlines closer to guidelines need to take the variety of social influences into account.

‘As a clinician, you are not managing lab results, you are managing the patient’: How the enactment of malaria at health facilities in Cameroon compares with new WHO guidelines for the use of malaria tests

“…Together with clinicians' consideration of the whole person, including their capacity for appreciating and/or paying for tests, this points to a broader interpretation of the role of clinician that is often neglected in simplified clinical algorithms and epidemiology based targets for 'rational drug use.' These findings, of broader context and expectations affecting diagnostic practice for malaria, are in line with the theory that clinicians operate with 'mindlines' rather than guidelines, as previously described in Tanzania (Chandler et al, 2008a) and Ghana (Chandler et al, 2010).…”

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“…Often such in-service training uses a didactic approach, presenting the case for rational drug use without accounting for wider determinants of practice, such as patient demand for certain drugs/services, or the influence of peers. 51 In addition, without follow-up supervision any improvements gained by training have been shown to severely deteriorate within a period of 12 months. 18 The approach adopted in IMCI training, which involves more interactive learning with the chance for clinical practice, has shown positive, albeit mixed, results.…”

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