A total of six males and six females were interviewed, including two clinical officers, one public health nurse, five staff nurses, two health orderlies and two medical assistants. Their age and work experience ranged from 25 to 64 years and four months to 37 years, respectively. The following major themes were identified:
Health care workers use caregivers’ history of illness and results of malaria RDTs as the primary influence on initial diagnostic and management decisions. Health care workers value caregiver history but suggest caregivers need more education to avoid late presentation to health facilities and poor health outcomes;
There is uncertainty regarding viral versus bacterial illness and health care workers feel additional point-of-care diagnostic tests would help with differential diagnoses;
Stock-outs of medications (primarily antibiotics) and limited caregiver resources are listed as barriers to delivering good care and as contributing to poor outcomes;
Health care workers list training, short courses and participation in research studies as major influences on diagnostics;
Weather also plays a role in diagnostic decision-making.
Theme 1. Health workers use caregivers’ history of illness and results of malaria RDTs as the primary influences on initial diagnostic and management decisions. Health care workers value caregiver history but suggest caregivers need more education to avoid late presentation to health facilities and poor health outcomes.
In the absence of tests for differential diagnosis of febrile illness, this study found that health workers rely heavily on the history of the fever as told by the mother for diagnosing RDT negative children.
“We usually ask the mother questions because we don’t have any other advance instruments or equipment to use.” (C8)
“We take history by asking mothers about diarrhoea, vomiting, convulsions, ear infection, coughing, fast breathing or normal breathing. Then we give diagnosis.” (C11)
“If the child is vomiting and has malaria symptoms but test negative then we ask the mother what other symptoms the child is suffering from.” (C12)
Several health workers describe the importance of details about the fever, particularly if it has been intermittent or constant. An intermittent fever was associated with malaria and a constant fever with influenza or a wound infection. Cough is also reported as an important symptom to discuss with the caregiver, to help differentiate pneumonia from other illnesses.
“The guardian can say the child has fever but you can ask them to tell you what kind of fever the child has, for example, my child is crying or is hot. You can ask how many days has your child had fever. With the guardian’s responses you can brainstorm and decide which investigation to carry out.” (C3)
“The most important thing is to know how many days the patient has had the fever. It is also important to know whether the fever has been constant or persistent. Also how the fever started. If the patient is coughing and has fever, we want to know which started first, fever or coughing. If coughing started first then that is the cause of the fever.” (C1)
However, health workers noted that caregivers often believe that any fever is malaria and thereby characterized their perceptions of malaria as outdated. While the epidemiology of malaria has changed in Zanzibar over the last 10 years , caregivers still associate the majority of illness with fever, and fever with malaria. Health workers identified this lack of awareness as an impediment to adequately characterizing fever.
“Every patient with fever imagines they have malaria… we try to advise that not every fever is malaria. We try to explain other causes of fever like tonsillitis, ear infection and urinary tract infection (UTI).” (C1)
“Most of the community members of [district] can’t differentiate which is fever because they think any condition they see, that even when someone has a wound, they say my child has fever.” (C3)
RDTs for malaria were listed by all the KIs as the first test given to a child with fever. Some health workers cited examples of how they improved caregiver acceptance of RDTs by educating them at appointments and enforcing diagnostic results. Over time, caregivers began to seek out diagnostic testing when their child had fever. RDTs were believed to facilitate febrile illness management when caregivers have been educated to believe the results. These health workers emphasized that the involvement of key stakeholders on all levels of the health systems, the use of various media approaches, and frequent exposure, are key to creating this change in attitude.
“Nowadays we don’t prescribe anti-malarials when one is RDT negative…When the child comes to the hospital we take history then we provide health education. We tell them there are a lot of things that cause fever so we have to carry out investigations to confirm malaria.” (C3)
“The patients don’t know the difference, homa is malaria and malaria is homa. If they have homa they ask for malaria medicine…We advise the patients to first take a test, and if they test positive they have malaria and if they test negative then they have fever caused by other diseases mentioned earlier or it could be flu.” (C8) (Author comment: Homa is the word for fever in Kiswahili but has a wider meaning including diseases associated with fever or higher than normal body temperature.)
“When we give health education frequently I think that can help us get the point we need…. When you give education to an individual there is change but it can’t happen in a few days.” (C3)
“Since they (RDTs) were introduced it has reduced malaria since a lot of people like coming to get tested. It has also made work easier.” (C5)
Although health workers rely on information from the mother, health workers in this study also described the mother as a barrier to health care, particularly their role in impeding positive outcomes. When asked why patients continue to die in Zanzibar despite the progress in malaria reduction, the majority of health workers in this study mentioned mother’s delay in bringing the child to the health facility because they are distracted by work, other caregiving responsibilities, and financial constraints.
“They are not treated early. Maybe the mothers delayed in bringing the children to hospital. So when they bring them the situation is severe and so when you treat it takes too long as they are so weak. Maybe they think that it’s just a fever because it is so cold, or they are too busy attending to family responsibilities, the father is away and left the mother with so many children and she has no time to get them to the hospital while others need to know the importance of health so that they can bring the children to hospital earlier. Most of the times we see the mothers are busy on the farm working, fishing, they do everything.” (C2)
Several health workers suggested that educating the caregiver would improve health outcomes in children by teaching precautionary measures that result in fewer illnesses as well as early recognition of dangerous symptoms.
“I think it is because the parents lack education. Parents need to tell the children not to play in the cold and wear warm clothing but sometimes the parents don’t follow instructions. Also kids play in dirty water and drink it so they get diarrhoea. We teach them about boiling water but the children are not always at home. When the children are playing outside the parents have no idea what they are doing but when they are indoors the parents will be able to watch and take care of them. I would make sure that there were enough…health education materials, especially for mothers in all facilities.” (C9)
“In our culture some people think that a child with severe anaemia is affected by devils so they delay to send to the hospital. If the child is sent to hospital early the health personnel can see that the child has severe [disease] and refer them for blood grouping and cross matching. This saves the life of the child.” (C3)
“Malaria has decreased but sometimes the problem is that mothers bring the children late to hospitals when the condition is already chronic.” (C8)
Theme 2. There is uncertainty regarding viral versus bacterial illness and health workers feel additional point-of-care diagnostic tests would help with differential diagnoses
Many of the health workers interviewed were unclear about the difference between viral and bacterial infection, especially in the respiratory tract.
“If the child has fever caused by infection, then we give antibiotics.” (C8)
Health workers generally agreed on what should be treated with antibiotics. These conditions included pneumonia, tonsillitis, ear infections, other respiratory tract infections, boils, cellulitis, skin infections, and urinary tract infections. However, one clinician also listed chickenpox and measles (both viral childhood diseases) when asked which diagnoses require antibiotics.
“We give antibiotics when they have pneumonia, ear discharge, gingivitis, and measles to reduce cough. Also, (we give antibiotics for) cellulitis, boils, abscess and chickenpox.” (C5)
When asked what to prescribe for a child with a negative malaria test, several health workers listed antibiotics as treatment for general flu.
“It depends on the situation. If the mother complains that the child is vomiting or has diarrhoea, worms, etc depending on the symptoms we prescribe drugs like mebendazole (Author comment: mebendazole is an antiworm medication used in Zanzibar and other settings to treat hookworm, roundworm, pinworm and other worm infections) or if it is flu we prescribe syrup or (antibiotic) depending on the child’s age.” (C12)
“For normal flu we give (antibiotic) syrup, if temperature is higher than 38.5 we prescribe paracetamol.” (C8)
Health workers believe additional tools will increase their diagnostic accuracy, although they are unsure of which tools they prefer (tools to diagnose urinary tract infection and influenza are mentioned most frequently). Additionally, they reported a lack of adequate staff and laboratory tests as barriers to differentiating causes of febrile illness.
“We use thermometers and stethoscope… we don’t have enough to check cultures, blood pictures, ESR.” (C2)
“I think every health centre needs to be better equipped and every laboratory should have a microscope. For example, children have anaemia but we don’t have the proper tools to determine that diagnosis.” (C8)
“There are a lot of other diseases like UTI infection we can’t diagnose because we don’t have investigation tool. We need laboratory equipment for UTI, Hb, and glucose because some come with hypoglycaemia… If a child has frequent fever, maybe no sign of malaria, test is negative and has no pneumonia, we need to check urine as a routine and for culture and sensitivity.” (C11)
“We have a laboratory that is not working as it has no personnel.” (C7)
“In my centre we got two great lab people but they were taken to another centre because we didn’t have the right equipment apart from a microscope.” (C8)
Theme 3. Stock-outs of medications (primarily antibiotics) and limited caregivers’ resources are listed as barriers to delivering good care and as contributing to poor outcomes
Primary health care facilities in Zanzibar receive antibiotics and other medications on a quarterly schedule from a central supply group. Health workers in this study repeatedly identified stock-outs as an ongoing problem, suggesting that halfway through the quarter many commonly prescribed drugs were unavailable. Likewise, a limitation to prescribing medications was the inability of caregivers to pay for the medications.
“Many patients are advised to buy medicine in private pharmacies. Some of them are available here for free but many of them are not available. Many of them are unable to buy the medicine. They return after two to three days without any medicine.” (C1)
“We get supplies but sometimes they are not enough to serve the children as the population [of district] has over 10,000 children. We can get syrup amoxicillin maybe four boxes of 24 so you can have (antibiotics) at the first of the month and none at the end of the month.” (C3)
“When the children come to the facility and we prescribe medicine they can’t afford the medicine. Sometimes the facilities don’t have enough drugs.” (C11)
“At the moment, many children are suffering from pneumonia so we prescribe medicine and then after a week they come with the same problem since some of them don’t buy the medicines.” (C12)
“In [district] there is a high illiteracy level… Also if they are transferred to (the local hospital) they can’t afford the transportation.” (C12)
Theme 4. Health care workers list training, short courses and participation in research studies as major influences on diagnostics
In addition to formal training, past work experience and short courses such as the WHO Integrated Management of Childhood Illness (IMCI), RDT-training and research study training, seem to shape health workers' understanding of diagnostic tools and their clinical approach to febrile illness in children under five.
Educational background varied greatly among the health workers. Clinical officers had longer training periods and felt more confident giving diagnoses. When asked what the difference between health workers was, one clinical officer said:
“I am better than others. (I am better) because of the course I took I am specially trained to review and diagnose the patients more closely so they recover quickly.” (C10)
Health workers also report that working in private health facilities has influenced their thoughts on causes of febrile illness, as these health facilities often have more diagnostic tools and advanced practice health workers.
“Also I am working in one dispensary in [district], this clinic is conducted by a paediatric consultant. He said that many patients admitted with fever, the main cause is urinary tract infection and not malaria. In this dispensary it is routine to do urinalysis in all patients and many of them it’s positive. When we give antibiotics the patients come back in two to three days in good condition.” (C1)
The majority of the study participants have participated in IMCI training and past research studies. This subgroup recognized IMCI as a useful guide to differentiating diagnoses of febrile patients.
“The training which gave me the knowledge and experience in febrile illness was the training on integrated management of childhood illnesses (IMCI).” (C3)
Participation in research studies where advanced tools were available to confirm or refute health workers’ diagnoses was an eye-opener in alternative causes of febrile illness.
“I was among the health workers who conducted RDT negative studies, the result hasn’t been sent back but I learnt a lot. There are some children we diagnosed as having common cold but when we sent to the laboratory the children had strep A positive (Author comment: “strep-A” refers to Beta-Streptococci group A test from a throat swab). IMCI says any fast breathing is pneumonia but when we did the RDT negative study we see few children with pneumococcal positive (Author comment: “pneumococcal” refers to Streptococcus pneumoniae antigen test in urine). We took urine culture during the study and some of the children had bacteria growth as sensitivity of the drugs. So the suggestion of any fever is malaria should be confirmed with diagnostic tools.” (C3)
“In RDT [negative] study we studied PCR, nasopharyngeal, streptococcus in urine. In normal conditions here this investigation is not done… We have no evidence to show that this (fever) is caused by bacteria. But according to signs and symptoms we can imagine it is caused by bacteria.” (C1)
Health workers that had previously received RDT training were vocal about why they like RDTs.
“RDTs are good and the results are rapid. It is also very simple to use and doesn’t take a lot of time.” (C6)
“They (RDTs) give accurate and timely results…especially the new type because you can know the type of parasite.” (C9)
However, four of 12 health workers interviewed had not received training when they started using RDTs. Health workers who had not received RDT training at the time of interview stated that RDT negativity does not rule out malaria.
“I know we use [RDT] to test for malaria but I don’t know the details… No, it’s not necessary [for RDT to be positive in diagnosing malaria].” (C2)
“RDT has uncertainties… People don’t believe the results.” (C4)
Theme 5. Weather also plays a role in diagnostic decision-making
The majority of the health workers in this study used weather seasonality to explain changes in febrile illness incidence. Certain conditions were associated with either the rainy season or the dry season.
“Febrile diseases usually occur in the rainy season when the body provides a mechanism to cope with the cold season. The summer is a normal season for them so the cold season is when they get fever.” (C3)
When asked about the cause of fever in children:
“Mostly it’s due to the weather especially when it is cold, children are coughing and have flu and fever.” (C4)
“During the rainy season we get a lot of diarrhoea cases and cholera. During the hot season we get flu because of the dust and conjunctivitis because of dust entering the eyes.” (C5)
“The rainy season is mostly associated with diarrhoea.” (C8)