“Testing for malaria does not cure any pain” A qualitative study exploring low use of malaria rapid diagnostic tests at drug shops in rural Uganda

Abstract

The World Health Organization recommends all suspected malaria cases be confirmed with a parasitological test, typically a rapid diagnostic test (RDT), prior to treatment. Despite recommendations, many fevers presenting at private drug shops are treated presumptively as malaria without diagnostic testing. The purpose of this qualitative study was to describe community perceptions of RDTs and explore ways to improve malaria case management at drug shops in Bugoye, western Uganda. A total of 63 in-depth interviews were conducted between September and December 2021 with 24 drug shop clients, 19 drug shop vendors, 12 community health workers, and 8 health and community officials. Data was analyzed using thematic content analysis and narrative techniques. While drug shop clients valued RDTs, the cost of the test limited their use. Further, mistrust in negative results and fear about treatment options for conditions other than malaria led to nonadherence to negative RDTs. Improvement with antimalarials after a negative RDT, or no RDT at all, was seen as proof an individual had malaria, reinforcing the acceptability of liberal antimalarial use. Drug shop vendors were knowledgeable about malaria case management but financially conflicted between recommending best practices and losing business. While clients viewed drug shop vendors as trusted health professionals, health officials distrusted them as business owners focused on maximizing profits. Study results suggest public-private partnerships that recognize the essential role of drug shops, better incorporate them into the healthcare system, and leverage the high levels of community trust in vendors, could provide greater opportunities for oversight and training to improve private-sector malaria case management. Interventions that address financial barriers to RDT use, emphasize the financial benefits of malaria testing, increase vendor knowledge about illnesses confused with malaria, and improve the quality of vendor-client counseling could increase RDT uptake and improve adherence to RDT results.

Challenges in the distribution of antimicrobial medications in community dispensaries in Accra, Ghana

“…Shopkeepers who recently adopted rapid diagnostic testing reported selling antimalarials less often than they previously had when treatment routes were based only on symptoms. This reaffirms prior studies detecting high rates of overdistributing antimalarials for non-malaria cases [71–73]. The more prudent use of antimalarials after the introduction of rapid testing encourages upscaling access to diagnostic testing for malaria in order to prevent the overuse of antimalarials and accelerated resistance.…”

Private sector antimalarial sales a decade after “test and treat”: A cross-sectional study of drug shop clients in rural Uganda

“…When RDTs were conducted, clients who tested negative sometimes still purchased antimalarials (36%). Qualitative research in this setting found that these antimalarial purchases stemmed from vendor and client distrust in negative RDT results, and fear or uncertainty about treatment next steps for conditions other than malaria ( 41 ).…”

Point-of-care testing in private pharmacy and drug retail settings: a narrative review

“…The content of sensitization should emphasize the benefits of testing at private retailers without diminishing other healthcare sectors: for example, a qualitative study suggested that sensitization efforts should focus on emphasising the need for testing regardless of the location (public or private), and leverage the trust in drug shops, which could increase uptake at private retailers without diminishing the work of public healthcare [ 59 ]. In the reviewed studies, over 80% of customers were satisfied with POCTs [ 34 , 72 – 74 ], citing the convenience of testing locations [ 51 , 74 ], as they would not have to travel to hospitals [ 40 ].…”