Improving the effectiveness of point of care tests for malaria and anaemia: A qualitative study across three Ghanaian antenatal clinics

Background: Anaemia and malaria are both major contributors to maternal and child mortality, and morbidity, with some of the worst outcomes occurring in sub-Saharan Africa. Point of care tests (POCT), if used appropriately, provide a simple, inexpensive form of diagnostic testing, as a reliable alternative when laboratory tests are not readily available. In such resource limited settings, clinical staff tend to rely on symptom-based diagnosis and presumptive treatment. This study uses qualitative methods to identify the current practice of POCT use for malaria and anaemia, to explore the enablers and barriers to effective implementation of these POCT, and to determine how relationships between each of the stakeholder groups may impact on POCT use. Methods: Staff (clinical and laboratory) and patients (pregnant women) at three antenatal care facilities within the Ashanti Region of Ghana participated in interviews and focus group discussions (FGDs). An initial coding framework was developed based on the pre-defined objectives of the study. Thematic analysis was used to identify subthemes and categories within each of the key themes. Results: At the time data were collected all three facilities used malaria POCT either as an adjunct to microscopy, or as their only form of malaria testing. Although all three facilities were familiar with haemoglobin colour scale (HCS), none of the facilities used them routinely. Clinical staff perceived symptom-based diagnosis was a quick way to diagnosis because access to POCT during consultations was unreliable, but recognized disadvantages associated with symptom-based diagnosis. Perceived advantages of malaria and anaemia POCT were user-friendliness, improved diagnosis and opportunity for patient engagement, as well as lower cost implication for patients. Perceived disadvantages included likelihood of missed diagnosis of mild anaemia, as well as likelihood of human error leading to in accurate diagnosis which could impact on patient trust. Poor communication and lack of trust between staff groups was also identified as a barrier to effective uptake of POCT. Conclusions: Consistent supply of POCT as well as staff training and staff and patient engagement, are fundamental to successful uptake of POCT for effective malaria and anaemia management. Three antenatal care facilities within the Ejisu-Juaben Municipality and Sekyere-East District of the Ashanti Region of Ghana were selected to participate in the study from April to June 2015. The Sekyere-East district is predominantly rural while the Ejisu-Juaben municipality has semi-urban and rural areas. Antenatal facilities within the two districts had been identified and mapped as part of an earlier study which aimed to determine the effectiveness of pregnant women’s active participation in their antenatal care for the control of malaria and anaemia in pregnancy [9]. Researchers from the initial study provided recommendations on the selection of facilities to provide a diversity of contexts including type of facility, size and source of funding. Two of the three facilities selected were government funded – one hospital and one health centre. The third facility was a privately funded maternity home. Antenatal care services on specific days as well as drop-in advice sessions were offered in all selected facilities. The average number of first-time attendees per month at the government hospital, government health centre and private maternity home were 153, 16 and 67 respectively [9]. All three facilities had laboratories and trained laboratory staff. Rapid diagnostic tests were used routinely at all three facilities when testing for malaria. The HCS had been previously piloted in two of the three facilities to estimate haemoglobin values for anaemia screening as part of the initial study. A control facility from the earlier study was selected as the third facility for the current study to help explore whether there may be any differences in the perspectives regarding POCT between those which had used HCS and those which had not. Interviews and focus group discussions (FGDs) were conducted amongst clinical and laboratory staff as well as pregnant women of each of the three facilities. The facility visits, which lasted approximately half a day, took place on days that antenatal clinics were known to run, and laboratory staff were also present. Each facility was visited twice at times that ensured the same laboratory and midwifery staff were present. The three antenatal clinics were midwife led, with a combination of midwives and nurses offering services to pregnant women. Auxiliary staff included health assistants, health extension workers and ward assistants with varying levels of formal nursing training of 1 year or less to none but the development of knowledge and skills on the job during their employment. Clinical staff who were directly involved with requesting and/or performing malaria and anaemia testing were invited for interview (participants were purposively selected to maximise diversity in expertise and seniority). They consisted of midwives and midwife/ward assistants. Laboratory staff who were present at the facilities visited were also invited for interview. All women aged 18 years and above, who were attending antenatal clinic appointments on the day of the facility visit, were invited to participate. Data collection was undertaken by three qualitative researchers who had been involved in the initial study [9] using semi-structured interviews and FGDs; these are available as Additional files 1, 2, 3 and 4 (supplementary materials). Guides were developed to cover the scope of the research objectives and were informed by the findings of the initial study [9]. The data collection was done in two visits to each facility using interviews and FGDs which lasted 30 to 60 min, and 45 to 75 min, respectively. In total, nine FGDs and eleven interviews were conducted across all three facilities. FGDs amongst pregnant women consisted of two stages at each of the three health facilities visited, as well as one FGD amongst ANC and laboratory staff at each facility. Interviews amongst laboratory and ANC staff were stopped when the point of saturation was reached. For clinical and laboratory staff, the first visit involved semi-structured interviews and explored topics in current practices for diagnosis and treatment of malaria and anaemia and their perceived advantages and disadvantages, communication and relationships between laboratory and antenatal staff, and usage and perceptions of POCT for anaemia and malaria. At the second visit, FGDs were conducted which explored barriers preventing the effective use of POCT, potential strategies for promoting change to ensure POCT effective use, and identification of key stakeholders necessary for implementing these changes. The purpose of the two visits was to explore differences between the clinical and laboratory staff groups, as well as their working relationships. For the pregnant women, FGDs were conducted in each facility at both visits. This involved groups of 8 to 16 pregnant women who were only allowed to participate once to avoid their views being presented twice. Their perceptions and experiences of malaria and anaemia testing were explored as women from a variety of backgrounds but having in common pregnancy and sharing the same antenatal care services. In order to explore relationships between the pregnant women and clinical and laboratory staff, vignettes were used to elucidate how women would respond if treatment was prescribed by staff when they were aware that they had tested negative for anaemia or malaria. If a participant was not aware of POCT, a brief technical explanation was given to aid discussion. Interviews were conducted in English and translated into the local language (Twi) by another member of the research team, as required. All FGDs were conducted in Twi to reduce the impact of language and cultural barriers. FGDs and interviews were audio recorded with permission from the participant(s) and were transcribed into English for analysis. Audio recordings were transcribed verbatim by the research team. Participants were assured that information would be gathered, processed and analysed in confidence; any quotes used would not be personally identifiable. All transcribed data were imported onto NVIVO 12 (windows version 12.5, 2019) to be analysed and interpreted through content analysis to develop research headings, categories and subcategories. Data was independently classified and analysed by two investigators (TP and AA) to enhance the credibility of the categorisation. To deepen insights and ensure findings reflected the research context, analysis of data was regularly reviewed by the research team who had carried out data collection. A coding framework was initially developed by one researcher based on the pre-defined objectives of the study and elaborated by a preliminary review of the data to understand the narratives portrayed by participants. Themes were discussed and agreed with a second researcher. Inductive coding was used to identify subthemes within each of the key themes. Themes were illustrated with quotes which were also mapped into the framework. The quotes were labelled using generic job roles to ensure anonymity. FGD participants were assigned a letter to which personal information (e.g. age, education level) and quote transcription was attributed. The study, including interview and FGD guides, participant information and consent forms, were approved by the ethics committees of the Liverpool School of Tropical Medicine UK, and the School of Medical Sciences in Kumasi Ghana, prior to the start of the study. Information regarding the study was explained verbally to participants prior to interview and FGDs. Participants were also provided with information sheets before seeking their consent using pre-prepared consent forms. Participants were informed that the information they provided would be collated, analysed and circulated and consent reaffirmed. All of this was explained in the local language whenever required.