title: Challenges with implementing malaria rapid diagnostic tests at primary care facilities in a Ghanaian district: a qualitative study.
abstract: BACKGROUND
  Rapid diagnostic Tests (RDTs) for malaria enable diagnostic testing at primary care facilities in resource-limited settings, where weak infrastructure limits the use of microscopy. In 2010, Ghana adopted a test-before-treat guideline for malaria, with RDT use promoted to facilitate diagnosis. Yet healthcare practitioners still treat febrile patients without testing, or despite negative malaria test results. Few studies have explored RDT implementation beyond the notions of provider or patient acceptability. The aim of this study was to identify the factors directly influencing malaria RDT implementation at primary care facilities in a Ghanaian district.
  
  
  METHODS
  Qualitative interviews, focus groups and direct observations were conducted with 50 providers at six purposively selected primary care facilities in the Atwima-Nwabiagya district. Data were analysed thematically.
  
  
  RESULTS
  RDT implementation was hampered by: (1) healthcare delivery constraints (weak supply chain, limited quality assurance and control, inadequate guideline emphasis, staffing limitations); (2) provider perceptions (entrenched case-management paradigms, limited preparedness for change); (3) social dynamics of care delivery (expected norms of provider-patient interaction, test affordability); and (4) limited provider engagement in policy processes leading to fragmented implementation of health sector reform.
  
  
  CONCLUSIONS
  Limited health system capacity, socio-economic, political, and historical factors hampered malaria RDT implementation at primary care facilities in the study district. For effective RDT implementation providers must be: (1) adequately enabled through efficient allocation and management of essential healthcare commodities; (2) appropriately empowered with the requisite knowledge and skill through ongoing, effective professional development; and (3) actively engaged in policy dialogue to demystify socio-political misconceptions that hinder health sector reform policies from improving care delivery. Clear, consistent guideline emphasis, with complementary action to address deep-rooted provider concerns will build their confidence in, and promote uptake of recommended policies, practices, and technology for diagnosing malaria.
authors.affiliation: School of Public Health, University of Alberta, Edmonton, Canada. boadu@ualberta.ca.|Nursing Best Practices Research Center, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada. boadu@ualberta.ca.
authors.forename: Nana Yaa
authors.initials: NY
authors.lastname: Boadu
authors.affiliation: Kumasi Collaborative Center for Research in Tropical Medicine, (EOD Group) KNUST, Kumasi, Ghana. amuas001@umn.edu.
authors.forename: John
authors.initials: J
authors.lastname: Amuasi
authors.affiliation: Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana. ansongd@gmail.com.
authors.forename: Daniel
authors.initials: D
authors.lastname: Ansong
authors.affiliation: Department of Communication and Culture, University of Calgary, Calgary, AB, Canada. einsiede@ucalgary.ca.
authors.forename: Edna
authors.initials: E
authors.lastname: Einsiedel
authors.affiliation: Health Technology and Policy Unit, School of Public Health, University of Alberta, Edmonton, Canada. menon@ualberta.ca.
authors.forename: Devidas
authors.initials: D
authors.lastname: Menon
authors.affiliation: School of Public Health, University of Alberta, Edmonton, Canada. yanow@ualberta.ca.|Alberta Provincial Laboratory for Public Health, Edmonton, Canada. yanow@ualberta.ca.
authors.forename: Stephanie K
authors.initials: SK
authors.lastname: Yanow
mesh_terms: D000328:Adult; D000368:Aged; D003955:Diagnostic Tests, Routine; D005260:Female; D005869:Ghana / Q000453:epidemiology; D019983:Guideline Adherence; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000706:statistics & numerical data*; D036301:Qualitative Research; D055815:Young Adult