title: A Qualitative Study Investigating Experiences, Perceptions, and Healthcare System Performance in Relation to the Surveillance of Typhoid Fever in Madagascar.
abstract: BACKGROUND
  The burden of typhoid fever (TF) in sub-Saharan Africa is largely unknown but is increasingly thought to be high, given that water and sanitary conditions remain unimproved in many countries. To address this gap in information, the Typhoid Fever Surveillance in Africa Program (TSAP) founded a surveillance system for TF in 10 African countries. This study was a component of the TSAP surveillance project in Madagascar.
  
  
  METHODS
  The study entailed a qualitative assessment of patients' experiences and perceptions of services for febrile symptoms at the studies' rural and urban sentinel public health clinics. The study examined influences on the use of these facilities, alternative sources of care, and providers' descriptions of medical consultations and challenges in providing services. Data were collected through semistructured and open-ended individual interviews and a focus group with patients, caregivers, and medical personnel.
  
  
  RESULTS
  Thirty-three patients and 12 healthcare providers participated in the data collection across the 2 healthcare facilities. The quality of services, cost, and travel distance were key factors that enabled access to and use of these clinics. Divergent healthcare-seeking patterns were related to variability in the care utilized, socioeconomic status, and potential distance from the facilities : These factors influenced delivery of care, patient access, and the health facilities' capacity to identify cases of febrile illness such as TF.
  
  
  CONCLUSIONS
  This approach provided an in-depth investigation and understanding of healthcare-seeking behavior at the study facilities, and factors that facilitated or acted as barriers to their use. Our findings demonstrate the relevance of these public health clinics as sites for the surveillance of TF in their role as central healthcare sources for families and communities within these rural and urban areas of Madagascar.
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Alfred
authors.initials: A
authors.lastname: Pach
authors.affiliation: University of Minnesota, Minneapolis.
authors.forename: Michelle
authors.initials: M
authors.lastname: Warren
authors.affiliation: International Vaccine Institute, Seoul, Korea London School of Hygiene and Tropical Medicine, United Kingdom.
authors.forename: Irene
authors.initials: I
authors.lastname: Chang
authors.affiliation: International Vaccine Institute, Seoul, Korea London School of Hygiene and Tropical Medicine, United Kingdom.
authors.forename: Justin
authors.initials: J
authors.lastname: Im
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Chelsea
authors.initials: C
authors.lastname: Nichols
authors.affiliation: Institute of Tropical Medicine, Eberhard-Karls University Tübingen, Germany.
authors.forename: Christian G
authors.initials: CG
authors.lastname: Meyer
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Gi Deok
authors.initials: GD
authors.lastname: Pak
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Ursula
authors.initials: U
authors.lastname: Panzner
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Se Eun
authors.initials: SE
authors.lastname: Park
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Vera
authors.initials: V
authors.lastname: von Kalckreuth
authors.affiliation: Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
authors.forename: Stephen
authors.initials: S
authors.lastname: Baker
authors.affiliation: University of Antananarivo, Madagascar.
authors.forename: Henintsoa
authors.initials: H
authors.lastname: Rabezanahary
authors.affiliation: University of Antananarivo, Madagascar.
authors.forename: Jean Philibert
authors.initials: JP
authors.lastname: Rakotondrainiarivelo
authors.affiliation: University of Antananarivo, Madagascar.
authors.forename: Tiana Mirana
authors.initials: TM
authors.lastname: Raminosoa
authors.affiliation: University of Antananarivo, Madagascar.
authors.forename: Raphaël
authors.initials: R
authors.lastname: Rakotozandrindrainy
authors.affiliation: International Vaccine Institute, Seoul, Korea.
authors.forename: Florian
authors.initials: F
authors.lastname: Marks
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008270:Madagascar / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D062486:Public Health Surveillance; D036301:Qualitative Research; D014435:Typhoid Fever / Q000453:epidemiology* / Q000523:psychology* / Q000628:therapy; D055815:Young Adult
keywords: healthcare utilization; illness experience; surveillance; typhoid fever