Health Policy and Planning Advance Access published online on March 4, 2008
Health Policy and Planning, doi:10.1093/heapol/czm046
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Malaria overdiagnosis: is patient pressure the problem?
1 Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
2 Joint Malaria Programme, PO Box 2228, Moshi, Tanzania
3 Kilimanjaro Christian Medical Centre, PO Box 2228, Moshi, Tanzania
* Corresponding author. London School of Hygiene and Tropical Medicine, 51 Bedford Square, London, WC1B 3DP, UK. Tel: +44 (0) 20 7299 4749 or +255 787 367473. E-mail: clare.chandler{at}lshtm.ac.uk
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Abstract |
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Objective In Africa antimalarials are often prescribed when malaria is unlikely, a problem that is becoming critical as more expensive antimalarials replace established drugs. However, little is known about what drives the overuse of antimalarials. We conducted this study to explore to what extent current prescribing behaviour in hospitals is driven by patient demand.
Methods Consultations were observed followed by exit interviews with patients or caretakers. Five district hospitals where microscopy was routinely available were selected in areas of low (n = 3) and high (n = 2) malaria transmission in north-eastern Tanzania. All outpatient consultations during the study period were observed (n = 669). Those sent for a malaria blood slide or treated with antimalarials presumptively were interviewed (n = 326). At the end of the study, clinicians were interviewed for their opinions on the use of antimalarials.
Findings Patients were not observed to demand antimalarials from clinicians, but occasionally asked for a malaria slide. Patient satisfaction on exit was similar between those prescribed antimalarials and those not prescribed antimalarials, but more patients or carers expressed satisfaction when the patient had been tested than when not. Clinicians rarely reported perceiving patient demand for antimalarials and asserted that such demand for medication would not affect their prescribing behaviour.
Conclusions Patient demand was not found to be driving the over-prescription of antimalarials found in the hospitals in our setting. To the contrary, the involvement of patients may provide an opportunity to improve prescribing practice if their expectations for testing and treatment in line with test results can be effectively communicated to clinicians.
Key Words: Patient expectations, antimalarials, clinical decision making
KEY MESSAGES
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Introduction |
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Malaria has become a default diagnosis for acute febrile illness in many African settings where up to half of all patients seen in outpatient clinics are diagnosed with malaria (WHO Roll Back Malaria, undated). Antimalarial treatment is frequently prescribed despite a negative blood slide result, or is prescribed presumptively (without recourse to parasitological testing) even when the probability of malaria is very low or the likelihood of patient immunity to severe malaria is high (Barat et al. 1999
; Makani et al. 2003; Amexo et al. 2004; English et al. 2004; Reyburn et al. 2004; Zurovac et al. 2006). While a low threshold for treatment is reasonable in young children in endemic areas, widespread use of antimalarials in other groups is difficult to justify.
The problems that result from overuse of antimalarials are being thrown into focus by the current replacement of established antimalarials throughout Africa with artimisinin combination therapies (ACTs) costs of which are typically 10-times greater (Wiseman et al. 2006). In addition, overdiagnosing malaria can lead to failure to treat for potentially more fatal bacterial disease (Evans et al. 2004; Okubadejo and Danesi 2004; Reyburn et al. 2004; Berkley et al. 2005). Improving diagnostic behaviour is thus a high priority, but it is likely interventions will need to be complex: simply providing alternative testing methods alone is insufficient (Reyburn et al. 2007). An understanding of what drives this behaviour, particularly in hospital settings where a higher standard of care is expected, is essential in designing such interventions.
A medical prescription offers a technical solution to a health problem but also symbolizes a satisfactory conclusion to a social interaction where expectations of both the patient and doctor are influential (Marinker 1973; Stimson and Webb 1975). In developed countries over-prescription of antibiotics, particularly for upper respiratory infections (Macfarlane et al. 1997), has long been linked to patient expectations for these drugs (Muller 1972), although several studies have demonstrated that physicians often overestimate or misinterpret patients’ expectations for them (Britten and Ukoumunne 1997; Mangione-Smith et al. 1999; Karras et al. 2003). In developing and middle-income countries, several studies have demonstrated how patient preference can stimulate inappropriate antibiotic prescribing and polypharmacy (Paredes et al. 1996; Howteerakul et al. 2003).
Given the scale and importance of the problem in relation to malaria, it is important to consider the effect of patient expectations for antimalarial drugs on clinician behaviour. We thus undertook this study to explore patient expectations, and clinician's perceptions of these, in relation to antimalarial prescribing in northeast Tanzania.
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Methods |
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The study was conducted in an area of Tanzania that includes a wide range of transmission intensities between the East African coastal plain and Mount Kilimanjaro. The epidemiology of malaria in the region has been reported in previous publications (Drakeley et al. 2005
; Reyburn et al. 2005). Five public hospital mother and child health (MCH) outpatient departments were identified as being representative of public hospitals that served populations living at high (two hospitals) or low (three hospitals) transmission intensity of P. falciparum. In each hospital the outpatient staff were sensitized to the study and agreed to participate. As is common in Tanzania, clinical staff consisted of clinical officers (COs) or assistant medical officers (AMOs) with 3 or 5 years of medical training, respectively; no fully trained MDs were observed. Hospitals were visited consecutively, and one week was spent in each hospital.
Two of the six study team members observed MCH consultations. These were observed consecutively, and where two clinicians were working simultaneously, one researcher observed each. More than two clinicians working simultaneously is rare, and mother and child clinics are only operational for a set period of the day, therefore we believe we captured all patients presenting at the mother and child clinics during the study period. The study took place during the rainy season when malaria is expected to peak. A further two members of the study team conducted exit interviews with patients, another (RM) conducted clinician interviews and a sixth researcher acted as patient co-ordinator.
Patients were sensitized to the study in the outpatient waiting area through poster displays and leaflet distribution, and verbal consent to participate was obtained. The research assistants observing consultations were medically trained and recorded whether and by whom malaria was first raised and, if it was raised, how it was discussed, and what diagnosis or other explanation was given. The data collection form is available from the authors upon request. The content of consultations was, as far as possible, transcribed verbatim (word-for-word) by the research assistants. All research assistants were trained in rapid note-taking and transcribing techniques, taking the opportunity of short time lapses between patients to add detail and writing the notes out long hand at the end of each session. Patients who were admitted to the ward were excluded.
Patients whose consultation had been observed were identified on exit and asked if antimalarial treatment had been prescribed or if a malaria slide had been requested (confirmed by inspection of the prescription or laboratory request slip). If one of these applied, patients were invited for a brief (approximately 5 minutes) interview conducted in KiSwahili in a secluded area of the clinic with one of two research assistants trained in interview and note-taking techniques. The patient coordinator was responsible for ensuring that all patients sent for testing were identified, for recording their test results and for inviting patients for interview. Questions were semi-structured, following a set format (available from the authors) with stem questions on the patient's perception of their diagnosis, attitude to blood slide testing, and feelings about the consultation in general and their prescription in particular. Clarification was sought through additional questions and prompts. The researcher noted down responses as near verbatim as possible during the interview. Clinical staff whose consultations had been observed were interviewed individually at the end of the study period in each hospital by a university trained sociologist (RM) and interviews were recorded verbatim by a second researcher. These interviews also followed a set format (available from the authors) but were more exploratory and therefore longer. Topics related to decisions regarding malaria testing and antimalarial treatment, and their perceptions of patient expectations and demands. Tape recorders were not used either during consultations or interviews as we considered this would affect the behaviour and responses of participants beyond the effect expected from the presence of an outside researcher.
Data analysis
Quantitative data were double-entered using Microsoft Access (Microsoft Corp. 2002). Qualitative data were transcribed from hand-written notes and translated; translations were checked and corrected by a pair of assistants, each being mother-tongue English and Swahili speakers, respectively. These files were then entered into the qualitative analysis computer programme Nvivo version 2 (QSR International Pty 2002). Quantitative data, including demographic variables, were double-entered using Microsoft Access (Microsoft Corp. 2002) and the database was uploaded into Nvivo for analysis alongside the qualitative data. The qualitative data were coded first by hand by both CC and RM to agree on coding definitions, and this coding scheme was then used and developed upon in Nvivo by CC. The open nature of the interview questions allowed unpredicted concepts to emerge and categories such as satisfaction with the consultation outcome were inductively generated and coded (meaning, for example, that the same respondent could be coded for expressing both satisfaction and dissatisfaction). Codes were created to encapsulate recurring themes and the entire dataset was revisited with the final coding scheme, resulting in a systematic coding of the original data. Codes were grouped and explored in relation to each other, using the quantitative data alongside the qualitative data, and hypotheses were generated in this manner, inductively derived from the data using grounded theory (Strauss and Corbin 1990). Differences between groups of responses were analysed quantitatively using chi-square tests by exporting data to Stata 8 (Statacorp, Texas 2003) for analysis, and differences were considered significant at the 95% level (P < 0.05).
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Results |
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Study population
Consultations with 669 consecutive patients were observed, with none refusing. In all, 326 (49%) patients were either sent for a blood slide or treated presumptively, but 49 (15%) had severe disease and were admitted, leaving 277 patients eligible for interview. Of these, 33 patients were lost to follow-up, absconding before interview, giving a sample of 244 (88%) patients included in the study (Figure 1). There were similar numbers of consultations and clinicians observed at each hospital except for hospital 3 which serves a smaller local population (Table 1). Half of the patients included were children under 5 years and, overall, half were female; 85% of the caretakers were female. The consultations of 22 clinicians were observed, with no refusals, and 17 took part in the interviews, with the remaining five unavailable at the time of interview. Of the clinicians observed, six were female (five interviewed) and five were AMOs (four interviewed, all male).
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Antimalarial treatment
Presumptive antimalarial treatment, without malaria testing, was prescribed to 20% of patients. Of those who were tested, 18% were slide positive and were all prescribed antimalarials. Of slide-negative patients, 33% were prescribed antimalarials, with clinicians at three hospitals prescribing antimalarials to more than half of patients with negative slide results (Table 2). In the remaining two hospitals, the prescription of antimalarials was lower, at around 10%, a variation not apparently related to level of health worker (AMOs were only present in hospitals 3 and 4) or the local transmission intensity of malaria.
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Consultation observations
Consultations lasted for a median of 3 minutes for the initial consultation (range less than a minute to 14 minutes) and 2 minutes for the follow-up consultation (range less than a minute to 11 minutes). Clinicians appeared to direct the course of the interviews in most cases, with only 15% of patients or caretakers initiating new topics or questioning the clinician. A typical consultation is shown in Box 1, with Box 2 showing an exchange in the more unusual circumstance of a patient challenging a clinician's decision to treat with antimalarials. No patients or caretakers were observed to request antimalarials verbally from the clinician. In eight (1%) cases the patient or caretaker suggested a malaria diagnosis to the clinician, for example, ‘doctor, my child has malaria’. Amongst these cases, antimalarials were prescribed to six, one of whom was slide positive and two of whom were treated presumptively without tests. In four (<1%) cases the patient or caretaker asked the clinician for a malaria slide and all of these were slide-tested, of whom one was slide positive but three were prescribed an antimalarial.
| Box 1 A typical consultation Patient 80110, female, 2 Doctor: What is the problem with the child? Patient: She has stomach ache and pain in the legs. Doctor: How old is she? Patient: 2 years 7 months. Doctor: Go and take this medication. [No slide taken, prescribed SP and paracetamol]
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| Box 2 A rare patient challenge to his clinician during a consultation Patient 80033, male, 42 years Initial consultation Doctor: What is the problem? Patient: Homa [fever] and a runny nose. Doctor: Go to the lab for a blood test and then bring back the results to me. Follow-up consultation Doctor: Malaria parasites were not detected; I will prescribe antimalarials ... Patient: But doctor I think I must be having typhoid because of the symptoms that I told you. Doctor: Do you know the symptoms for typhoid? Patient: No. Doctor: Then why do you say you might be having typhoid while you do not know the symptoms for typhoid? Does it mean now that even the prescription that I will give you will be of no use, if you do not believe that it will help you? Patient: There was a time I had the same symptoms and I was tested for malaria that turned out to be negative, when I was tested for typhoid the results were positive, that is why I am suspecting that I could be having the same illness. Doctor: Which hospital did you go for the test that time? Patient: In the dispensary. Doctor: I am very surprised nowadays patients like going in the private dispensaries where you are diagnosed with fake illnesses, don't you know that what they are interested in is your money? First of all the homa [fever] that you have is not the same as that of a patient with typhoid; when you have typhoid, the fever is severe, it rises and cools a bit like a stepladder. But then again, you only have the right to know the results of what you have been tested for, the illness that you have and the medication, you have no right whatsoever to tell me what to do and how to do it. [Slide negative, diagnosed with malaria, prescribed amodiaquine and paracetamol]
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Clinician interviews
Patient demand for antimalarials was only cited by three (of 17) clinicians as grounds to treat slide-negative cases with antimalarials, in contrast to reasons such as the possibility of lab errors or the parasite prevalence in the area the patient is from (Table 3). Clinicians reported, often strongly, that they would not be swayed by patient demands in their judgement regarding antimalarial treatment. This was true whether patients were perceived to want antimalarials or refused to take antimalarials when they had a negative slide result (Box 3).
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| Box 3 Clinicians reported recognizing but not responding to patient demands Clinician 1002, female clinical officer RM: Do you feel that some patients come to see you with certain expectations with regards to malaria tests and treatment? CO: There are many who demand to have a test for malaria or demand to be given a certain antimalarial ... When such patients come, I request them to explain to me how they feel; as a doctor I decide about the kind of test that should be done and the type of medicine to prescribe ... We usually tell patients like these that medical tests are not done randomly and drugs are not given because a patient demands them ... There are other patients whose blood slide is negative and they do not want to be given malaria drugs: sometimes they escape home without any medicine (even though we would like to prescribe them some), and may go to other hospitals, but these patients stay away for a very short time and then become sick again and so return to the hospital, when we explain to them that we do not depend on test results to prescribe medicine ... instead we give them medicine depending on their complaints; sometimes we may give them antimalarials without carrying out a malaria test. Clinician 8003, male assistant medical officer "Most patients come from the dispensaries where they have been told that they have certain diagnosis; I have to educate them after finding the correct diagnosis and correct treatment".
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Patient interviews
Patient satisfaction (and dissatisfaction) was coded from positive (or negative) comments about their consultation made spontaneously by patients during exit interviews. Comments coded as ‘satisfied with consultation’ included:
‘I have been told the child has malaria and am happy because it's good to know what the child is suffering from, and as a parent you stop worrying.’ (Mother of patient 10062, female, 5 years)‘I feel good because I have known my problem and am happy with the medication because the doctor is an expert and that is why I came for tests so that I could know my problem.’ (Patient 80022, male, 22 years)
‘I feel good because the doctor has used the tests to know my problem, I am happy with the way the doctor has listened to me carefully and the treatment he gave me.’ (Patient 90165, male, 75 years).
Comments coded as ‘dissatisfied with consultation’ included:
‘I have not been told what the child is suffering from and I feel so bad. I am not satisfied with the way he has just prescribed medication without explaining anything to me. I have no choice but to use his prescription.’ (Mother of patient 10110, female, 2 years)‘I was told that she has malaria but am not satisfied because she has not been tested. I wanted her to be tested first so that I can be assured what she is suffering from. When I told the doctor that I wanted the child tested he told me there is no need, and I have no choice but to accept what the doctor has said; the child is very weak and he sleeps all the time.’ (Mother of patient 80132, female, 1 1/2 years)
‘I feel bad because I have been tested and I would have loved to know what I am ailing from. The doctor did not explain anything; he just prescribed medication and told me to go to the pharmacy. I am not happy with the doctor's service.’ (Patient 90135, male, 15 years)
Such expressions of satisfaction or dissatisfaction were not associated with having received an antimalarial (Table 4). When patients or caretakers reported being happy with their consultation, this was often described as being because of having been tested, having medication prescribed, and being treated by a clinician (Box 4). However, not all patients were happy about the judgement of the clinician, and some reported having ‘no choice’ but to accept the clinician's decision, whether that was a malaria diagnosis with antimalarial treatment or a non-malaria diagnosis with no antimalarials given (Box 5).
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| Box 4 Patients wanted testing, medication and treatment by a clinician Patient 90095, male, 4 years Int: Do you know the results of the test? Mother: I am not comfortable with the way the doctor has just prescribed medication without testing the child first, we can also buy the drugs at home and give them to our children if that is all that we wanted, but we come here for tests! [No slide requested, prescribed amodiaquine, cotrimoxazole, paracetamol] Patient 10144, female, 30 years Int: What diagnosis did the clinician give to you? Pt: I have been told that I do not have malaria. Int: How do you feel about it? Pt: I feel okay because the clinician has prescribed some medication for me ... Int: Do you know the results of the test? Pt: I have been told that I do not have malaria though the clinician has prescribed malaria tabs, and that is okay with me because sometimes when you get tested for malaria, the parasites are not seen, the medication will help me ... Most of the times when I come to be tested for malaria the results show negative but when I use medication I recover. Int: Did you take any antimalarials before coming to the hospital today? Pt: No, I knew it was best to first get tested so that I could be sure of what ailment I had, because one can use a drug for the wrong ailment and when the body gets used to that specific drug and you fall ill the body would not respond to that treatment since it has gotten used to it ... [Slide negative, prescribed SP, paracetamol]
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| Box 5 Some patients expressed that they had no choice but to accept the diagnosis or treatment given by the clinician Patient 30061, female, 23 years Int: Do you know the results of the test? Pt: The doctor did not tell me the outcome of the test results and I am very angry because of that. I came here to know what my problem was because last night I did not sleep, my entire body was sick, I came here for tests so that I could know my problem and now it seems I have wasted my time, if I just wanted medication I would have gone to the pharmacy and bought drugs by myself if that is what I wanted! But I came here so that I could be tested and to know my ailment ... I feel so bad for not knowing what my ailment is, but I have no choice I will go and use the medication he has prescribed and if I do not recuperate then I will go to another hospital for more tests so that I can know my problem. [Slide negative, prescribed amoxycillin and diclofenac] Patient 40011, female, 2 years 9 months Mother: I do not feel good because I wanted the child to be tested first so that he could be given medication, but now since there is nothing I can do, I will just follow the doctor's instruction and give the child the medication and see how he will fair, perhaps the doctor has suspected that the child has malaria because of the symptoms that the child has. [No slide requested, prescribed SP and paracetamol]
Patient 90174, male, 2 Int: What diagnosis did the clinician give to you? Mother: Malaria. Int: How do you feel about it? Mother: The doctor told me he has malaria but I am not happy because he was not tested, the doctor just presumed that he has malaria because of the symptoms that I gave him. I have just accepted the treatment because the child is very sick and I cannot go back home without medication ... [No slide requested, prescribed amodiaquine and paracetamol]
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Patient satisfaction was found to vary within hospitals, and as this was not associated with having been given antimalarials, we explored other potential reasons why different groups of patients might have reported being satisfied more than others, displayed in Table 4. Satisfaction appeared to be unaffected by whether the interviewee was the caretaker (in 82% of cases the mother) of a child under 15 or was an adult patient.
Having been tested increased the frequency of satisfaction expressed (although not statistically significantly, P = 0.192), and this was particularly noticeable among adult patients. Ninety-two per cent of adults were sent for a malaria slide compared with 74% of children. Amongst patients who were tested, 81% of slide-positive and 76% of slide-negative patients had been told or had read their results. Knowing the test result was statistically significantly associated with expressing satisfaction at interview. Of these patients, those who knew they were slide positive expressed satisfaction more frequently (borderline significance, P = 0.058) than those with slide-negative results. This satisfaction did not appear to be affected by the type of treatment prescribed, whether antimalarial or other treatment such as antibiotics.
Nearly half (43%) of all patients and caretakers interviewed expressed trust in the clinician at some point in the interview and this confidence did not vary greatly by the age or gender of patient, whether the patient was tested or treated presumptively, the result of the slide test or whether antimalarials were given (range 37–44%).
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Discussion |
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Key findings
Consistent with other studies, we found that antimalarials were often over-prescribed. However, this over-prescription did not appear to be the result of patient demand. Patients rarely suggested antimalarial treatment in consultations and the prescription of antimalarials was not associated with patient satisfaction or dissatisfaction expressed at exit interviews. Correspondingly, clinicians rarely perceived patient demand as a major influence on their choice of treatment. Patients reported an expectation for tests and for treatment to correctly follow test results, but were mostly happy to accept decisions made by the clinician even if this did not appear consistent with slide results. Although rarely explicit, patient preference for slide testing may have influenced clinical decisions.
The consultation process
The consultation process has been characterized as serving to legitimize the patient's illness, with the physician's authority maintained by his competence and association with the medical profession (Parsons 1951). For a satisfactory outcome for both the clinician and patient, there are therefore two aims for the consultation: to provide technically correct care, but also for this to correspond with the patient's expectations in order to legitimize their illness. Biomedical care has thus developed a pattern during the consultation whereby the clinician takes on a role with authority over the body of the patient and the patient is essentially passive. However, a process of negotiation can take place within this relationship (Stimson and Webb 1975). In order for the patient to be satisfied, clinical decisions must be mediated by what the clinician thinks the patient wants.
In this study, we identified a set of objectives from patient and caretaker interviews that included tests to be taken and medication to be prescribed, preferably following test results, and for the process to be under the control and guidance of a clinician. This is consistent with previous findings. A community study in central Tanzania identified trust in the provider along with drug availability and quality of care provided as key influences in the selection of primary health care facility (Gilson et al. 1994). Similarly, in a study on views of hospital care in Zambia, technical quality of care, represented by thoroughness of examination, was valued highest by patients, followed by staff attitudes and drug availability (Hanson et al. 2005). Patients are therefore mindful of both technical and personal aspects of care, and seem unlikely to be attending health facilities with a demand for particular medications in mind. The increased satisfaction with knowing results and with a positive malaria result is likely to reflect the need for patients to know their diagnosis (Brown 1995), and also may reflect the greater social acceptability of malaria as a diagnosis compared with other diseases (Mwangi 2006), particularly when proven parasitologically.
That clinicians reported being unaffected by patient expectations may reflect normative statements (responding how they felt they should as clinicians), and some did identify patient expectations for antimalarials or for specific tests as affecting their work. Whilst no direct requests for antimalarials were observed during consultations, on the few occasions when a slide was explicitly requested, the clinician complied. Further ethnographic research in these hospitals suggests that clinicians do perceive and respond to a demand for testing, particularly amongst adult patients. This suggests that our findings are consistent with others in that patients do have expectations from their consultations and that clinicians may perceive and respond to them. However, patient expectations in this setting appeared not to be specific to antimalarials as has been found with antibiotic usage in other developing country settings (Paredes et al. 1996; Howteerakul et al. 2003). This difference may reflect both the setting and the disease: previous research has been conducted in settings where patients are exposed to more intense advertising from drug companies, and much has related to the treatment of diarrhoeal disease with oral rehydration solution, a problem involving a different set of cultural preferences (Mull and Mull 1988; Nichter 1988; Howteerakul et al. 2003).
The hospital setting
We chose to situate this research in hospital outpatient departments, a setting where the overdiagnosis of malaria has been widely reported. We hypothesized this setting would reveal social influences on behaviour better than health centres where this would be complicated by logistical and resource issues. While antimalarials are easily purchased over-the-counter in Tanzania as elsewhere in sub-Saharan Africa (Williams and Jones 2004), and at lesser cost in terms of time and travel (Goodman et al. 2004), many patients still choose to attend hospitals for treatment of febrile illness (de Savigny et al. 2004). In southern Tanzania, patients attending drug stores were found to have the same levels of parasitaemia as those attending health facilities but sought a different process: that of purchasing medication (most often antipyretics rather than antimalarials) often without asking for advice from the pharmacist (Kachur et al. 2006). This suggests patients select the source of health care according to factors other than their clinical symptoms. The strong history of government provision of health care in Tanzania may contribute to patients feeling reassured by a ‘proper’ medical consultation in a health facility where they can attain legitimization of their illness. Hospital outpatient settings are likely to set a standard for the expectation of the delivery of care generally, but it is possible that in private health facilities medical staff may be under greater pressure to please patients and therefore may prescribe differently.
Limitations
There are a number of limitations to the interpretation of this study. Firstly, the generalizability is limited due to the sample selection methods. Clinicians were sampled on the basis of working in the MCH at the time of the visit, which may not be representative of clinicians usually working in such settings, although all clinicians did agree to be observed. Whilst all patients visiting the MCH during the study period were observed, the sample is still selected from a point in time and may not represent typical consultations or opinions at other times of the year or malaria season. Our results are specific to treatment seeking and treatment giving at hospitals in northeast Tanzania and therefore may not be representative of other outpatient settings such as health facilities. Patients may seek different processes of care from different providers, and clinicians may perceive different pressures when working at community-level health centres. In these settings we would expect the influence of social interaction to be as strong if not stronger than in the more formal hospital setting. Further research into community-based expectations for malaria treatment and into interactions with clinicians at health centres is needed to identify whether our findings are generalizable to the wider health-seeking population.
The study focused on patients considered by the clinician to have or potentially have malaria because we were interested in whether those who had received antimalarials had demanded or expected them. We therefore did not interview patients not considered for malaria and this limited our ability to compare patient satisfaction with other treatment decisions. No identity of clinician was recorded during consultations so we could not relate patient satisfaction to clinician data, such as clinician grade or sex.
Informing public health strategies
A key strategy to improve targeting of antimalarials is to make their use dependent on a positive parasitological test (Amexo et al. 2004; Njama-Meya et al. 2007), but this is hampered by deeply entrenched beliefs that a negative blood slide does not rule out malaria. Our findings suggest that patients are unlikely to resist initiatives to respect slide results; patients preferred to be slide-tested and stated that treatment should be in line with results. Clinicians in our study often cited biomedical reasons for their current prescribing behaviour and some of these may be amenable to reason (e.g. parasite sequestration, epidemiological likelihood) supported by the provision of more accurate tests (e.g. through laboratory quality control, rapid diagnostic tests). However, the lack of evidence for lasting changes to prescribing behaviour through persuasion of clinical logic (Ofori-Adjei and Arhinful 1996) or dissemination of more reliable tests (Reyburn et al. 2007) suggests social reasons are still likely to underlie behaviour.
Establishing clear guidelines (currently often ambiguous about the significance of a negative slide result) will be important in supporting behaviour change, and training and supervision are likely to be successful to some degree. However, the social context of prescribing also needs to be addressed. We did not find that patients demanded or preferred antimalarial treatment, but that clinicians did perceive patient preferences as a factor that affected their decisions. We suggest that the involvement of patients may provide an opportunity to improve prescribing practice if their expectations for testing and treatment in line with test results can be effectively communicated to clinicians.
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Ethical approval |
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This research was conducted with the ethical approval of LSHTM and the National Institute for Malaria Research, Tanzania. Free and informed consent of all participants was obtained.
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References |
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Accepted for publication 23 October 2007.
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