Malaria diagnostic tests
Although generally positive, attitudes towards and awareness of malaria testing varied across the sites. Pregnant women, and the community in general in central Ghana, accepted healthcare staff as providing accurate diagnoses of their health complaints, whether blood analyses were carried out or not. Women could however not always recall the purpose of the tests – for malaria or otherwise – during clinic visits.
I: How would you know a pregnant woman has malaria?
R: It is only when she goes to the hospital would they be able to tell whether she has malaria or not because pregnant women are often weak. So you might even think she is sick when she is not.
(Central Ghana, in-depth interview with the husband of a pregnant woman, 35 years old)
In northern Ghana, pregnant women identified contradictions between the messages provided in health facilities and their own experiences of malaria: some women complained of being frequently told that malaria was the reason they were feeling unwell, whereas, on other occasions, they thought that they had malaria but were not given treatment. As the quotation below suggests, ambiguity was often linked to the breadth of the local illness concept that approximated to biomedically defined malaria (as is discussed in more detail elsewhere [
10]).
I: Did you not have malaria at a point in time?
R: Ok. There was a time when I went and told [the healthcare staff] that I had malaria and they told me that we should not always say that we have malaria, but we should just say that we are sick, because we cannot tell whether it is malaria or not. But I know that I had malaria because I was vomiting.
I: Did they give you any malaria drugs?
R: Yes they gave me some. They made me go and do some test before they gave me that medicine.
(Northern Ghana, an in-depth interview with a pregnant woman, 29 years old, one child)
At both sites in Ghana, health professionals described the importance of diagnostic tests for accurate malaria diagnosis. In these settings, however, health professionals also explained that infants and pregnant women were exceptions to the new policy on malaria case management that stipulated a positive malaria test prior to administering anti-malarials. Hence, pregnant women were observed receiving anti-malarials without being tested (even if a test was available) or despite a negative malaria test result.
In Malawi, pregnant women viewed malaria diagnostic tests as ambiguous. Although not always available, when they were available, positive results were often trusted and seen as confirmation of a diagnosis. In cases of a negative result, the test was sometimes viewed as missing the infection. The subsequent lack of treatment also disappointed women who had assumed that they were suffering from malaria and expected to be treated. However, the following quotation from a focus group is one example of the reports of treatment in spite of a negative test result.
I: Can one have malungo (malaria) without knowing?
All: Quite.
[…]
R5: We get tested and then you know that you have malungo even when you go [to the clinic] for another disease and not malungo.
I: Is it possible to feel that you have malungo and at the hospital they do not find it?
R1: Yes, it’s possible.
All: Yes.
I: So what happens when you have all the symptoms and they do not find the malungo?
R5: They give AL (artemether-lumefantrine).
All: Yes.
(Malawi, a group discussion with local women)
In contrast, interviewed Malawian healthcare staff only referred to treating after a positive result. Moreover, malaria-like symptoms were said to be common amongst pregnant women, but the rapid diagnostic test confirmed a minority of these cases as malaria (one health worker referred to one in ten).
Kenyan respondents generally valued diagnostic tests for malaria (and other diseases): they viewed them as accurate and associated them with more effective treatment. Indeed, one pregnant woman’s husband stressed the need to travel the extra distance to the district hospital to ensure access to diagnostic tests. Nonetheless, respondents described having “malaria”, particularly mild “malaria”, without having obtained a diagnosis (either from a health worker based on clinical presentation or the result of a blood test). This was linked to the broad illness category of “malaria” that respondents described, which did not necessarily match the biomedical definition [
10].
For the most part, malaria tests were only available free of charge through the laboratories of medical research institutes that were carrying out clinical studies within the grounds of health facilities. In smaller health centres, a malaria test was only available with the assistance of staff from the medical research institutes, who tested non-study patients when requested by healthcare staff or when severe malaria was suspected. At the district hospital, although malaria tests were sometimes available in the Ministry of Health laboratory, charges were commonly levied for these tests. There were therefore reports of healthcare staff administering anti-malarials without a test.
Sometimes you may go to these [drug] shops and tell them your problems for example, I have a headache but they will not do a lab test so they will just give you medicine thinking that it is malaria but it is not. Now it is good to go to the hospital and get tested so that you may know the problems that you are suffering from
(Kenya, in-depth interview with a pregnant woman, 20 years old, two children)
Indeed, Kenyan healthcare staff viewed malaria – symptomatic and asymptomatic – as common amongst pregnant women. In light of this, a diagnostic test was viewed as essential to confirm the diagnosis.
R: At least, out of all the admissions, you will find that eight out of ten will have malaria. Almost all. And half of them never feel ill. So when you take the temperature that is when you realise but they don’t complain. You see the [blood] slide.
I: So you are saying that eight out of ten have malaria and most of them are not complaining.
R: Yeah most of them don’t complain, they just see it as part of the discomfort of pregnancy but when now you are doing your research, and doing the blood tests, they will say “ah, I don’t even have malaria”, and you say let’s check. And you check and you will see and have to treat, so that’s malaria.
(Kenya, in-depth interview with a healthcare provider)