Eleven staff members across all sites agreed to be interviewed; seven midwifery staff and four laboratory staff (Table 1). There were no refusals to participate. Quotes from staff are cited with clinical/laboratory and facility and no further details to maintain confidentiality; quotes from pregnant women are cited with age and facility used (Table 2).
Table 1. Facility and Job Role of ANC/Laboratory Staff Study Participants
Facility
|
Job Role
|
Length of Service at Facility
|
Government Hospital (GH)
|
Midwifery Officer
|
7 years
|
Government Hospital (GH)
|
Senior Midwifery Officer
|
8 years (with previous experience elsewhere)
|
Government Hospital (GH)
|
Deputy Head of Nursing
|
12 years (with considerable previous experience elsewhere)
|
Government Hospital (GH)
|
Deputy Head of Laboratory Services
|
1.5 years (with 1.5 years’ experience elsewhere)
|
Government Hospital (GH)
|
Laboratory Assistant
|
19 years (with previous experience elsewhere)
|
Government Health Centre (GHC)
|
Midwifery officer
|
2 weeks (with previous experience elsewhere)
|
Government Health Centre (GHC)
|
Principal Laboratory Assistant
|
13 years
|
Private Maternity Clinic (PMC)
|
Ward Assistant
|
11 years
|
Private Maternity Clinic (PMC)
|
Midwife in-charge
|
21 years
|
Private Maternity Clinic (PMC)
|
Ward Assistant
|
2 years (with 1-year experience elsewhere)
|
Private Maternity Clinic (PMC)
|
Laboratory Scientist
|
13 years
|
Current practice for anaemia and malaria testing
All three facilities used mRDTs for testing; the government hospital (GH) as an adjunct to microscopy, the other two (GHC &PMC) as their only form of malaria testing. At the Private Maternity Clinic (PMC), the midwives and health-care assistants used rapid diagnostic tests at the point of care as standard practice, however, midwives sought clarification from the doctor and/or laboratory staff when results conflicted with their clinical judgement. At GH and PMC, the type of mRDT being used could not be established because staff often procured their own from local pharmacies. During FGD with clinical and laboratory staff (GH), it was reported that testing was only for falciparum malaria, therefore when negative, results did not exclude the possibility of non-falciparum malaria. The clinical and laboratory staff during FGDs felt that there was a higher prevalence of non-falciparum malaria in reality than the national estimated prevalence of 7% (Quote 1-2; table 2).
Although all three facilities were familiar with HCS, none of the facilities used them routinely. PMC had previously used HCS as part of the initial study. Anaemia diagnosis at each of the facilities was undertaken as follows:
- Government hospital: Full blood count machine, spectrophotometry, and haematology analyser.
- Government health centre: No laboratory anaemia diagnosis carried out due to resource limitations.
- Private maternity clinic: Sahli Method of Haemoglobin Estimation
All facilities utilised clinical diagnostic methods for both anaemia and malaria irrespective of laboratory findings. Symptoms used to diagnose malaria included: abdominal pain, fever, headache, chills and a bitter taste in patients’ mouth. Signs used to diagnose anaemia included: pallor of conjunctiva, tongue and palms. In general, the clinical judgement determined whether a patient was treated or not, irrespective of the laboratory test result (Quote 3-4; table 2).
Across all three facilities, training had been sporadic and improvised for the laboratory staff. None of the facilities visited reported having regular and consistent training on anaemia or malaria and their diagnostics. When it did happen, it was reported that one staff member attended training and was expected to disseminate the knowledge across the organisation as appropriate. There were no explicit mechanisms in place for this to be done, causing staff to operationalise guidelines for practice differently. There also seemed to be a limited understanding regarding the rationale behind stipulated guidelines, which meant that staff had inadequate information to identify and/or address the poor practice. The lack of knowledge also led to limitations in considerations for differential diagnosis of malaria and anaemia (Quote 5; table 2).
Perceptions about tests for malaria and anaemia
The laboratories reported turnaround times between 2 and 45 minutes for malaria and 5 and 15 minutes for anaemia (where done) which they felt was prompt, and up to an hour at peak periods. However, ANC staff at two of the facilities (PMC and GH), felt that results usually took too long to return. The women likewise felt that the testing and consultation process was time consuming.
Regarding accuracy of results, laboratory staff recognised some limitations with the POCT they used but generally felt that the tests were accurate. At GHC in particular where only mRDTs were available to test for malaria, the laboratory staff felt the limitations of mRDTs made them significantly inferior to microscopy for malaria diagnosis. ANC staff expressed concerns that human error also led to inaccuracies in laboratory tests (e.g. mixing up of patient results), despite also having reservations regarding the accuracy of POCT.
Perceptions of advantages and disadvantages of point of care testing for malaria and anaemia
A range of advantages and disadvantages about malaria and anaemia POCT were identified by the groups (Figure 1). The pregnant women did not identify any disadvantages.
Figure 1. Perceived advantages and disadvantages of Point of Care Testing for malaria and anaemia
Despite identifying a number of disadvantages for the use of POCT, clinical staff were all keen for both the roll out of HCS and change in protocol to recommend that anaemia and malaria POCT be undertaken by all clinical staff, if they were not already doing so. They expressed no concerns regarding the impact of taking on the task on their existing workload. The laboratory staff on the other hand felt that clinical staff would not have the necessary training to safely carry out the task such as use of personal protective equipment that could impact on both staff and patient safety. There were also concerns of accuracy of the result due to human errors that could lead to discrepancies in patient diagnosis (Quote 6; table 2).
Although the laboratory staff acknowledge the usefulness of POCT especially in emergency cases when laboratory services could not be accessed, they felt that increasing access to POCT for pregnant women could also negatively impact on demand for laboratory services in future. This, they felt, would significantly reduce their workload, and consequently their job security.
Perceptions and drivers of symptom-based diagnosis
At two out of the three facilities, clinical staff felt that symptom-based diagnosis was quicker and cheaper than other forms of diagnosis because access to their own stock of POCT during consultations was unreliable. Clinical diagnoses were used as a primary method of diagnosis of malaria and anaemia, and to justify treatment in those who had had negative test results from either POCT or other forms of laboratory testing. Staff also perceived that their seniors used symptom-based diagnosis as a default method. Although staff reported to having received guidance from the government and other external agencies that treatment should not be decided from symptom-based diagnosis, in practice this guidance was largely ignored (Quote7; table 2).
The ANC staff generally felt that symptom-based diagnosis is an effective and efficient means of testing and that each facility had methods in place to ensure appropriate use of it. At PMC and GHC, the staff reported that it was left to senior members of midwifery staff to decide whether to treat for malaria, even when mRDT provided negative test results. Figure 2 outlines key drivers and justifications for the use of symptom-based diagnosis as expressed by the clinical staff
Figure 2. Key drivers and justifications for the use of symptom-based diagnosis by clinical staff
Laboratory staff highlighted a number of problems associated with symptom-based diagnosis. Primarily, they felt that the symptoms used for diagnosis of anaemia and malaria are not pathognomonic, leading to an over-diagnosis and over-treatment of malaria and, to a lesser extent, anaemia. They felt that this practice increased the risk of anti-microbial resistance to malaria drugs and an overuse of already stretched blood stocks for transfusions (Quote 8; table 2).
Although laboratory staff attended training about overdiagnosis and overtreatment of malaria and anaemia, there was no formal way of ensuring these messages were disseminated across the facility. Nevertheless, they felt that the clinical staff should already be aware of this and expressed their frustration about being helpless to change behaviour as symptom-based diagnosis was routinely adopted as the diagnostic of choice across the country (Quote 9-10; table 2).
Inter-relationships between ANC and laboratory staff, and patients
Relationships between ANC and laboratory Staff
Observations at all three facilities highlighted a potential lack of effective communication leading to mistrust between laboratory staff and clinical staff. Communication of results between the staff groups was mainly via written result slips, couriered by the patient. GH laboratory staff stated that they regularly requested feedback regarding unusual results in order to check quality of the result, as well as to promptly identify problems with laboratory testing (Quote 11; table 2).
Notwithstanding, ANC staff felt they could not rely on laboratory diagnostic results alone and therefore often preferred to trust their clinical judgement. They recollected previous evidence to suggest that the laboratory results were often incorrect (Quote 12; table2).
Likewise, laboratory staff did not consider that clinical diagnostic methods to be accurate and felt that clinical staff should not be responsible for managing POCT and their use. The lack of trust and power relations was further displayed during joint focus groups. During FGDs, controversial statements were made by laboratory staff regarding POCT use by clinical staff (Quote 13; table 2). The clinical staff choose not to voice opinions or challenge speculative comments made by laboratory staff, until they were encouraged by the focus group facilitators (Quote 14; table 2).
Irrespective of hierarchy and trust concerns impacting staff relationships, clinical and laboratory staff were able to demonstrate cooperation when it came to management of malaria and anaemia in pregnancy (Quote 15; table 3).
Relationships between ANC/Laboratory Staff and Pregnant Women
The pregnant women demonstrated a good understanding of tests that were required during their pregnancy. At the point of laboratory and POCT testing, the women could not identify which tests were being undertaken but this soon became clearer upon receipt of the result from the clinical staff. There was no indication from the women that they ever challenged the lack of information or asked questions (Quote 16; table2).
In contrast, laboratory and clinical staff felt that they did explain the tests that were being carried out to the women prior to testing. They discussed the role that pregnant women played in their diagnosis and treatment which showed variations in the perceived level of control and influence that the women had regarding treatment choices. Although they recognised that pregnant women’s treatment preferences may influence their clinical management, there was a general consensus rejecting the idea that the women should query their treatment. Nonetheless, they felt that the women retained the power to choose whether or not to adhere to recommended treatment, buttressed by the women, who also reported they recognised the role they had to play in their diagnosis and treatment (Quote 17-18; table 2).
A clinical staff member felt having a negative malaria test as a barrier for treatment adherence. She felt the women would not adhere to treatment if they were aware their test result was negative, which would also lead to reluctance to pay for the test and treatment. As a result, it was reported that the culture was not to test for malaria but to adhere to symptom-based diagnosis and presumptive management (Quote 19; table 2).
During discussion at FGDs, the women felt that clinical and laboratory staff were the main decision-makers in their treatment and had mixed opinions about the appropriateness of challenging clinical or laboratory staff if they were treating them despite a negative test result, speaking fondly of the clinical staff. However, this often translated into a fear of challenging the clinical staff which they felt could damage their relationship and potentially lead to annoyance of clinical staff (Quote 20; table 2).
All three stakeholder groups felt that POCT provided an opportunity for the women to see their results, which potentially increased patient engagement thereby improving treatment adherence. The women likewise felt that implementation of POCT by clinical staff would increase their involvement in the decision-making process of their treatment. The women also felt they would be well informed to challenge decisions made by the clinical staff (Quote 21-22; table 2).
The pregnant women had less interaction with the laboratory staff which was reflected in their perceptions. Although the laboratory staff agreed with clinical staff concerning pregnant women’s perception of POCT use, the laboratory staff who had contacted the pregnant women were male while the clinical staff described in the FGD were mainly female. This could have affected the interactions between the pregnant women and clinical and/or laboratory staff (Quote 23; table 2).
Table 2: Table showing listed verbatim quotes from participants (I= Interviewer; R= Respondent)
No
|
Setting
|
Participant description
|
Verbatim quote
|
1
|
FGD, GH
|
Laboratory and clinical staff
|
“We only test for the falciparum. So, if we say…if the results come from the lab says it’s negative, we don’t test for the others so we wouldn’t know if it’s really negative for the others or it’s a different condition presenting like that we wouldn’t know...”
|
2
|
FGD, GH
|
Laboratory and clinical staff
|
“R: I think some work has been done but estimated about 7%, is that right?
I: Between 6 and 7%, between 6 and 7%... How accurate do you think the RDTs are?
R: I think that brand is also important. Some of them are very accurate in picking but some…err I don’t know. But some don’t usually give you the positive that you want but if you do the microscopy you realize the organisms are there, but you don’t get the report from the RDTs.”
|
3
|
Interview, GH
|
Laboratory staff
|
“That’s what they used to say that oh we checked conjunctiva; it is pale. We checked the palms; the patient is pale and your Hb is… your Hb is not corresponding to the patient. But you see, if it happens like that we can’t do otherwise. If you repeat the test and the machine gives you the same value, there’s nothing you can do. You have to write that way so it’s left to the clinician to judge.”
|
4
|
Interview, GHC
|
Laboratory Manager
|
“I: Do you think that the doctors here trust the RDTs?
R: I don’t know anything about it whether they trust it or not.”
|
5
|
Interview, GHC
|
Clinic staff
|
“I- So someone could come to you with symptoms of anaemia but doesn’t actually have anaemia. Does that ever happen…?
R – No
I – …So those symptoms are always anaemia?
R – Yes”
|
6
|
Interview, GH
|
Laboratory staff
|
“I think so because some people can be colour blind. If they use this their judgement will be different from what’s really happening… sometimes too the RDTs when you use them, when you use the RDTs there can be very faint lines. I might see it but you might not see it.”
|
7
|
Interview, PMC
|
Clinical staff
|
“The people from the insurance office came to talk with us about that. If a person’s test comes out not positive, we should not treat it but if we should treat, we are to write the reason why we are treating it.”
|
8
|
Interview, GH
|
Laboratory staff
|
“She doesn’t understand, that’s how I see it. Sometimes, it’s a different sickness. It can be a different sickness but not malaria.”
|
9
|
Interview, PMC
|
Laboratory staff
|
“Yeah that one is a problem because these, if you have fever or your temperature is high, not only malaria can cause that so there is a problem. That what we know. We have a problem…. I think even the teaching hospitals they are doing it so there’s a problem.”
|
10
|
Interview, GH
|
Laboratory staff
|
“Eheee, they bring the request, we do it, there’s no malaria, they still continue to treat; not for all patients anyway. But for some of them they still continue to treat. We always complain, we always talk about that. They are trying to stop but they still do it anyway.”
|
11
|
Interview GH
|
Laboratory staff
|
“… sometimes we ask the prescribers and the nurses to give us feedback…maybe within a week, within a day or two if they are getting some, a particular range of Hbs that they doubt they should just let us know so that we…they draw our attention to the fact that maybe we may be having problems with the machine that we do not even know.”
|
12
|
Interview, GH
|
Clinical staff
|
“…they said the Hb was 9.4. but when you look at the face, conjunctiva and everything, I mean, there’s no blood at all. So, we gave 2 units and now she has been discharged this morning.”
|
13
|
FGD, GH
|
Laboratory staff statement during FGD
|
“… lab people will monitor its usage in the sense that maternity, we can give maternity a full pack [pack of POCT]. We want to monitor its usage because they will know how to use it, of course, but if it’s getting finished there they will have to account for it either sense because if we just bring it into the system just like that people will be doing it and some staff can even steal it and take it home; to do it for others for money meanwhile anything can happen so it has to be monitored but it would help.”
|
14
|
FGD, GH
|
Clinical staff statement during FGD
|
I: How do you feel about the monitoring aspect that the lab is talking about?
R: The monitoring she is talking about, I agree with her in some part but I disagree with her in a statement she made. We are unique individuals. You don’t know how people would…it is true, some people can take something outside, but I don’t think the ward in charge will just put the thing on the table that everybody can use it. I don’t think so. So, I agree with her but some statement I don’t agree with her.”
|
15
|
FGD, GHC
|
Clinic staff
|
“Aah, after I have done mine and seen that it is negative but still the client is insisting, I’ll let the lab man also come in.”
|
16
|
FGD, GHC
|
30 y/o, pregnant woman
|
“She places it under and sets it to see which colour matches… Please we saw that she was doing it like that, but she didn’t tell us what she was doing …. She did not say anything to us. She just pulled the paper and began to write.”
|
17
|
Interview, GH
|
Clinical staff
|
“No because when the patient comes, they expect to get something. At least if you give them... if nothing at all if you give them paracetamol, if you treat symptomatically without targeting the main cause of disease they would prefer it rather than telling them go, get worse and come back.”
|
18
|
FGD, GH
|
21 y/o, pregnant woman
|
“So, sometimes the fault is from us. Some people when admitted will rush and tell the doctor to discharge them when she is not even well.”
|
19
|
Interview, GH
|
Clinical staff
|
“At times when you do the test and it’s negative, it is nothing, no MPs seen, you can’t give the malaria treatment. If you give, they won’t pay, to be frank. They won’t pay so the protocol here is, when the mother presents the symptoms, then you can start the malaria [treatment].”
|
20
|
FGD, PMC
|
23 y/o, pregnant woman
|
“Please as long as we are human, if you argue with her about taking it, she will be angry. And when you come, what she has to do for you she will be reluctant and the love she has to demonstrate for you, she wouldn’t have that for you.”
|
21
|
FGD, GHC
|
30y/o, pregnant woman
|
“Just as she said. If there was one here and every time you came you knew where your blood level was, when you go home you will take care of yourself in terms of your diet.”
|
22
|
Interview, GHC
|
Laboratory staff
|
“It helps her too. When you are done you will show it to her, telling her that this is the amount of blood I got during the test. Then I will explain the colours for her to see whether her blood level is high or low… It helps them so that if they were not planning on taking the drugs, they take them this time.”
|
23
|
FGD, GHC
|
Facilitator discussing with pregnant women during FGDs
|
“Ok. Now you’ve told me that when you come here you report to the midwife. The midwife takes you through a lot of things and then directs you to the lab. The lab man also pricks your finger and asks you to wait outside after which he gives you your paper when it is ready, for you to take back to the midwife. You usually don’t know what requests for you to do at the lab. The particular disease, you are not aware of.”
|