The debate on RDTs has begun to shift from whether RDTs should be used, to how and under what circumstances their use can be optimized
. Calls for the increased availability of RDTs in both the public and private sectors, as part of efforts to rationalize the use of ACT
[28, 29] have increased demand for a better understanding of the complexities surrounding the role of RDTs in appropriate treatment of fever. This qualitative study has added to, existing understanding of clinicians’ interaction with RDTs following their introduction to health facilities in one district in Ghana
[8, 16], to explore the perceptions and experiences of patients and caregivers of children who had been tested as part of the trial.
In this study, patients who had been tested with RDTs held positive, but often technically inaccurate, perceptions of RDTs, and considered their role in accurate diagnosis and treatment of their illness to be valuable. Their expectations for the RDT to identify any cause of illness – not just malaria – could however in time compromise this apparent acceptability of the tests as they become more established in the health care context if not addressed, as it cannot be realized. Patient experiences of RDTs were embedded in existing hierarchical social relations between clinicians and patients, with patients perceiving limited ability to engage in the clinical process and to influence providers’ behaviour around testing and treating malaria. The finding that the technical mechanisms of RDTs were not seen to be part of the lay domain, combined with the perception of the diagnostic process as housed in the clinical domain, suggests that patient demand for treatment to directly follow test results in this setting is currently limited.
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]. 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
. However, beyond this, it was found that perceptions of RDTs were underpinned by unrealistically high expectations from the tests. 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
 and may reflect broader ideas that the quality of health care is equated with use of new technologies like RDTs
, framed by an assumption that problems are resolvable through technological means
Study respondents described the test as a ‘machine’, a descriptor also reported for RDTs elsewhere in Ghana
, suggesting recognition of a highly technological and complex process by which a result is produced. Beyond this, patients were unable to describe the processes of the RDT. Rather, the position of testing in a laboratory or special testing room outside of the lay purview, seemed to allocate to the test a status of mystery and power, described for biomedical investigations elsewhere
. This finding contrasts with the other study of patient experiences with RDTs in Ghana where patients were able to describe clearly the way the tests give results, in a context where the patients had attended study clinics, run by well-trained fieldworkers as part of a clinical research team
. It is possible that there the test was carried out more openly by the fieldworkers, along with explanations about the tests to patients. This may have affected some of their perspectives of the test as a more objective indicator of malaria than clinical opinion. In this study, where testing was incorporated into routine services, patients presented themselves as outside of RDT processes. Test results were elusive, and patients did not identify mechanisms by which the test should determine clinical management decisions. This suggests that the tests were not seen as independent objects, but as part of the clinical process under the expertise of the clinician.
The goal to achieve universal parasitological diagnosis of malaria through improved access to testing rests on the assumption that tests, such as RDTs, provide objective criteria for malaria diagnoses. As such, the tests are held to be the locus of knowledge for making a treatment decision. However, the findings of this study suggest that in a routine scenario in Ghana, RDTs were adopted into a practice where the clinician retains the locus of knowledge, and power, for clinical decisions. 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
, 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
The findings presented in this study suggest that, whilst RDTs are clearly welcomed by patients, two issues need to be addressed from the patient perspective in order for RDTs to achieve the potential intended by policy makers and funders. First, expectations that RDTs are able to diagnose any illness need to be managed in order to lessen risks of reduced acceptability of the tests since any mistrust of the new tests among the public will affect their acceptability
. Second, and related, the link between RDTs, their results, diagnoses and treatment decisions need to be made transparent. Both can be addressed through improved communication with patients, particularly by health workers themselves. The challenge faced by clinicians is to change an existing system of opaque diagnosis, embedded in a system of clinician authority and patient (blind) trust, to an open encounter that lays bare what is known and unknown in the process of test result-determined decisions. In the analysis of health worker experiences of RDTs in this same trial, respondents conveyed that investing in better communication with patients, particularly in the face of negative RDT results, was difficult at times but worthwhile
. Elsewhere, trials to evaluate the impact of the introduction of RDTs alongside supporting interventions that include training in improved communication are on-going and will inform methods for undertaking such interventions. Beyond goals to manage expectations from RDTs and promote test-based diagnoses, improved communication may influence patients’ and caregivers’ understandings of diagnoses and treatment regimens for febrile illness in general, potentially affecting adherence to treatment, perceptions of quality of care, and future care seeking decisions
[27, 35, 36].
The number of FGDs (six) and one interview conducted reflects a fairly small sample size, although no new themes or ideas were identified in the final discussions, suggesting that a level of saturation had been achieved. The study was conducted in a single district, which potentially limits the extent to which the results can be considered applicable outside the specific study context. However, many of the findings correspond with other, similar studies elsewhere including Ghana. The period that had elapsed between the time of visit and the FGD in the case of some respondents may have diminished recall to a certain extent, but this was not evident in the discussions as respondents appeared to talk easily about their experiences. The two groups of caregivers tended to narrate experiences from visits during their own recent illness episode as well as those of their children, and the two were often indistinguishable. It is possible that caregivers had themselves experienced RDTs as part of the trial at another point in time, giving them further insights into the test. In addition, the way testing was discussed, often as ‘testing’ rather than using a word for RDTs, suggests that broader experiences with testing are likely to have been drawn upon in the reflections of respondents. This has the potential to provide a more integrated narrative of RDTs in context but in places it also limited interpretations to testing in general rather than RDTs in particular.
Direct observations of clinician-patient interactions might have offered insight into how patients’ perceptions of RDTs were shaped by the clinical encounter in this context. However, we did not directly observe the interactions between the clinician and the patient as our focus was to understand how patients and local communities made sense of these interactions when RDTs are involved. In addition, direct observation would have had implications for the results of the randomized controlled trial in which this qualitative study was situated.