UCSF Benioff Children's Hospital Oakland, 747 52nd St, Oakland, CA, 94609, USA.
Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
Malar J. 2017 Sep 20;16(1):381. doi: 10.1186/s12936-017-2021-7.
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 differential when malaria testing is negative. Prior studies have indicated that resource availability, need for additional training in differentiating non-malarial illnesses, and lack of understanding within the community of when to seek care play a role in effective diagnosis and treatment. The objective of this study was to examine the various factors that influence clinician behavior in diagnosing and managing children presenting with fever to health centres in Kenya.
A total of 20 clinicians (2 paediatricians, 1 medical officer, 2 nurses, and 15 clinical officers) were interviewed, working at 5 different government-sponsored public clinic sites in two areas of Kenya where malaria is prevalent. Clinicians were interviewed one-on-one using a structured interview technique. Interviews were then analysed qualitatively for themes.
The following five themes were identified: (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 training modalities contributes to the difficulty 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 working in resource-poor environments still face difficulty when evaluating a child with fever, especially when malaria testing 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 intervention at both the clinic and community levels.
在疟疾流行地区资源匮乏的环境中，临床医生在诊断和治疗儿童发热方面面临诸多挑战。鉴于世卫组织 2010 年指南的变化，该指南建议在治疗前进行疟疾检测，因此现在要求临床医生在疟疾检测呈阴性时扩大鉴别诊断范围。先前的研究表明，资源的可获得性、在鉴别非疟疾性疾病方面额外培训的需求，以及社区对何时寻求医疗服务的理解程度，都对有效诊断和治疗产生影响。本研究的目的是探讨影响肯尼亚卫生中心临床医生诊断和管理发热儿童的各种因素。
总共对 20 名临床医生（2 名儿科医生、1 名医疗官、2 名护士和 15 名临床医生）进行了访谈，他们在肯尼亚两个疟疾流行地区的 5 个不同政府资助的公立诊所工作。临床医生使用结构化访谈技术进行一对一访谈。然后对访谈内容进行定性分析，以确定主题。
确定了以下五个主题：（1）对疟疾诊断和疟疾检测非常熟悉；（2）临床医生对社区对发热疾病的理解、使用传统医学、延迟寻求医疗服务和遵医嘱情况的担忧；（3）依靠临床指南、病史和体格检查来诊断发热疾病并识别危险信号；（4）临床医生对诊断原发性病毒疾病感到不适，导致经验性使用抗生素的情况增加；（5）缺乏资源，包括诊断检测、必要的药物和培训模式，这使得临床医生在评估和治疗儿童发热方面面临困难。尽管医疗服务水平存在差异，但这些主题在所有地点都存在。在这些主题中，临床医生一致表示需要可靠的基本检测，特别是全血细胞计数和细菌培养。临床医生讨论了使用咨询和教育来提高社区对发热疾病的理解，以减少儿童可预防的死亡。
本研究结果表明，由于疟疾检测已变得更加广泛，在资源匮乏的环境中工作的临床医生在评估发热儿童时仍然存在困难，特别是当疟疾检测呈阴性时。增加对其他诊断方法的获取、继续教育，以及对临床指南的持续评估和修订，可能会导致提供者更一致地管理发热疾病，并可能潜在减少不必要的抗生素的使用。社区层面的额外干预措施可能在管理发热疾病方面也具有重要作用，然而，还需要更多的研究来确定在诊所和社区层面的干预目标。
