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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