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Table 4 Influences and mindlines for malaria over-diagnosis

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

Sphere of influence

Motives for malaria diagnosis

Motives for not treating alternative diagnoses

Motives for treating alternative diagnoses

Mindlines

Patient outcome

Patient likely to be cured if malaria parasites present

 

Patient likely to be cured if no malaria parasites present at low endemicity, or even if parasitaemic at high endemicity (co-morbidity)

 

Diagnostic support

Easy and quick to diagnose and treat

More complicated diagnosis and treatment

 

Malaria is easier to diagnose than alternatives

 

Perceived as easily recognisable

Alternative diseases perceived as less specific

  
 

Fewer tests needed for confirmation

Increased number and complexity of tests (e.g. lumbar puncture)

  
 

Feel confident to diagnose clinically

Clinical diagnosis less clear, may need to wait for test results

  
 

Laboratory test results may be incorrect (due to resource problems, staff skills) or the parasites may be hidden

   
 

Well established process of malaria diagnosis and treatment

No set process: if time short or motivation low may be easier to take established path

  
 

No retribution for over-diagnosing malaria

Lack of supervision or regular advice to consider differential diagnoses

  

Disease promotion and training

Well known disease with frequent training available

Less well known diseases, less training available

  
 

Guidelines are malaria specific

Few guidelines for alternative diseases

  

Patient preferences

Perceived as preferable to patients

Fear of patient complaints if don't test or treat for malaria

  
 

Perceived as acceptable to patients: high profile, low-stigma disease

More explanation necessary for patients who may prefer the familiarity of malaria

 

Malaria is a more acceptable diagnosis

Peer pressure

Perceived as acceptable to peers who also see over-diagnosis as preferable to missing malaria

Alternative diagnoses may require clinicians to justify themselves

  

Disease promotion and training

Malaria promoted by public health campaigns as most important disease

Alternative diseases less often promoted resulting in lower profile

 

Missing malaria is indefensible

 

Training emphasises malaria over alternative diseases

Alternative diseases taught in theory more than practice

  
 

Indefensible to miss malaria, perceived as most important disease

More defensible to miss alternative causes of disease

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