Table 2 Key themes emerging from formative research

Tension between test results and experience

‘There is a test at the dispensary [RDT] but it is not trustworthy because you might be sick, or your child is sick, and when you go for a check-up they will tell you that you do not have malaria. So the best thing is to get a trustworthy test.’ (FGD#T3, 30-year-old man, subsistence farmer also a traditional healer)

‘We do not trust the test because everyone who goes for the test is told there is no malaria, but if you are given medication you feel better.’ (FGD#T1, 32-year-old mother of three, female subsistence farmer)

‘A patient came with all malaria signs, but the malaria test was negative. I was in dilemma. I was tempted to give the patient [antimalarial] medication.’ (IDI#T3, male nurse)

‘It affects me very much. Maybe when he or she came from his or her home place he or she had only an expectation to be helped and get the best services. So if you don’t give him or her correct treatment, to be frank it affects me and I extremely lose peace. You have to fulfill what the patient wants. When you don’t fulfill that, even by yourself you will not feel peace in your heart.’ (IDI#T1, female public health nurse)

‘Most of the time they [patients] don’t disturb though a few of them do. If you are not competent in your professional ways they will challenge you and say, “I have come here and I feel malaria completely.” When they test negative, they say “your test is not reliable” … One day a women came and shouted “these tests are fake!” Then I told her make a test somewhere else and come here to compare the results.’ (IDI#T2, female Maternal and Child Health (MCH) Aide)

Recognition of the need to change practice

‘If I compare with the present time, I think my prior form of diagnosis was not accurate because we used to see patients who would say they had fever, part of their body was sore, or that their body felt weak, and automatically we would say it was malaria. But since we started using this malaria test, we found that we were giving antimalarial treatment to many more patients than we do now.’ (IDI#K5, female clinical officer in-charge of dispensary)

‘We were not correct, because we were just guessing “that patient has malaria”, and we would give antimalarials. Since we received the test, we just get like three or five children with malaria out of twenty, while before the test we used to say all twenty had malaria because we would give antimalarials to whoever had fever.’ (IDI#T4, female nurse midwife in-charge of dispensary)

‘I am a patient, I go to the doctor, I tell him “give me quinine,” “give me ALU.” I don’t think it is the right way. It is better that the health worker is strong as a professional person who does a test and looks for the disease. Not how we are, so familiar with each other to ask, “give me quinine.”’ (FGD#K6, mother)

Resolving tensions of tests: questioning the process and rationalising presumptive treatment

‘When you test and the first patient is negative, the second is negative, then whoever you test results become negative … we met with our colleagues from [a neighbouring dispensary] and they said most of their tests are negative, we tried to find out reasons, for that and we found out that buffer leakage and buffer moving faster than normal were common problems.’ (IDI#T3, male trained nurse)

‘On my side, I will give him or her malaria drugs. I will not feel good [otherwise], I will ask question myself why I should not give this patient malaria drugs? … If I will leave the patient without giving him or her some drug to take it will not be good. I will advise him or her to take malaria drugs … and if he or she will continue being sick, he or she can come back for a check-up again.’ (IDI#K2, female MCH Aide)

‘Sometimes you may find a person who really needs my help with antimalarials, but the test shows no malaria. For that incident I prescribe antimalarials, but very rarely.’ (IDI#T5, female clinical officer in-charge)

Resolving tensions of tests with alternative diagnoses

‘If I test a patient as malaria negative, I will not give him antimalarials, but I will give an antibiotic. I have enough experience that sometimes patients come in very sick and I think they have malaria but when you test him you find no malaria, but when you give antibiotic then he recovered.’ (IDI#T6, male assistant clinical officer)

‘I tested myself in the dispensary near our home and thought that it was a joke. She took blood, put it on a testing device. Then after discussion for short moment she told me that I don’t have malaria though she would give me paracetamol tablets as headache pain killers so that I could feel normal. I was also told to avoid a lot of work and get rest. I truly followed the instructions and my condition got better. Maybe it was body tiredness and I felt alright.’ (FGD#K5, 48-year-old male, ward executive officer)

‘I tell them that a fever is not only a symptom of malaria, but other diseases as well. We tell them to take painkillers with them and that they should come back to the dispensary if there is no improvement … Yes in that situation I don’t treat them, but I reassure them that they don’t have malaria.’ (IDI#K5, female clinical officer in-charge)

Importance of time and experimentation in adopting RDTs

‘The first problem I had with it was that I could not understand why so many patients were found to be negative. Yet based on what I later found, some patients just had the flu, which is why they had a cough and fever. They never came back with the same symptoms which for me confirmed that this test was accurate.’ (IDI#K5, female clinical officer in-charge)

‘At the beginning, they [patients] do not trust this test, “this person is only playing on the table - no electricity, no any other thing. I don’t think this test is correct!” But as much as we continued to use it, they started to agree with us.’ (IDI#K3, female MCH Aide)