Principles, practices and knowledge of clinicians when assessing febrile children: a qualitative study in Kenya
Hooft, Anneka M
Masese, Linnet N
LaBeaud, A. Desiree
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Clinicians in low resource settings in malaria endemic regions face many challenges in diagnosing and treating febrile illnesses in children. Given the change in WHO guidelines in 2010 that recommend malaria testing prior to treatment, clinicians are now required to expand the diferential when malaria testing is negative. Prior studies have indicated that resource availability, need for additional training in diferentiating non-malarial illnesses, and lack of understanding within the community of when to seek care play a role in efective diagnosis and treatment. The objective of this study was to examine the various factors that infuence clinician behavior in diagnosing and manag ing children presenting with fever to health centres in Kenya. A total of 20 clinicians (2 paediatricians, 1 medical ofcer, 2 nurses, and 15 clinical ofcers) were inter viewed, working at 5 diferent government-sponsored public clinic sites in two areas of Kenya where malaria is preva lent. Clinicians were interviewed one-on-one using a structured interview technique. Interviews were then analysed qualitatively for themes. The following fve themes were identifed: (1) Strong familiarity with diagnosis of malaria and testing for malaria; (2) Clinician concerns about community understanding of febrile illness, use of traditional medicine, delay in seeking care, and compliance; (3) Reliance on clinical guidelines, history, and physical examination to diagnose febrile illness and recognize danger signs; (4) Clinician discomfort with diagnosis of primary viral illness leading to increased use of empiric antibiotics; and (5) Lack of resources including diagnostic testing, necessary medications, and train ing modalities contributes to the difculty clinicians face in assessing and treating febrile illness in children. These themes persisted across all sites, despite variation in levels of medical care. Within these themes, clinicians consistently expressed a need for reliable basic testing, especially haemograms and bacterial cultures. Clinicians discussed the use of counseling and education to improve community understanding of febrile illness in order to decrease preventable deaths in children. Results of this study suggest that since malarial testing has become more widespread, clinicians work ing in resource-poor environments still face difculty when evaluating a child with fever, especially when malaria test ing is negative. Improving access to additional diagnostics, continuing medical education, and ongoing evaluation and revision of clinical guidelines may lead to more consistent management of febrile illness by providers, and may potentially decrease prescription of unnecessary antibiotics. Additional interventions at the community level may also have an important role in managing febrile illness, however, more studies are needed to identify targets for interven tion at both the clinic and community levels.