• 1.

    Greenlee JE , 1990. Approach to diagnosis of meningitis. Cerebrospinal fluid evaluation. Infect Dis Clin North Am 4: 583598.

  • 2.

    Scheld WM , Whitley RJ , Marra CM , 2014. Infections of the Central Nervous System. Philadelphia, PA: Wolters Kluwer Health.

  • 3.

    Siddiqi OK , Ghebremichael M , Dang X , Atadzhanov M , Kaonga P , Khoury MN , Koralnik IJ , 2014. Molecular diagnosis of central nervous system opportunistic infections in HIV-infected Zambian adults. Clin Infect Dis 58: 17711777.

    • Search Google Scholar
    • Export Citation
  • 4.

    World Health Organization , 2020. The Selection and Use of Essential In Vitro Diagnostics. Geneva, Switzerland: WHO.

  • 5.

    World Health Organization, World Federation of Neurology , 2017. ATLAS: Country Resources for Neurological Disorders. Geneva, Switzerland: WHO.

    • Search Google Scholar
    • Export Citation
  • 6.

    Parry E , Godfrey R , Mabey D , Gill G , 2004. Principles of Medicine in Africa. Cambridge, UK: Cambridge University Press.

  • 7.

    Herbert G , Ndiritu M , Idro R , Makani JB , Kitundu J , 2006. Analysis of the indications for routine lumbar puncture and results of cerebrospinal fluid examination in children admitted to the paediatric wards of two hospitals in East Africa. Tanzan Health Res Bull 8: 710.

    • Search Google Scholar
    • Export Citation
  • 8.

    Thakur KT et al., 2015. Lumbar puncture refusal in sub-Saharan Africa: a call for further understanding and intervention. Neurology 84: 19881990.

    • Search Google Scholar
    • Export Citation
  • 9.

    Saylor D , Elafros M , Bearden D , Dallah I , Mathews M , Mwenechanya M , Siddiqi OK , Sikazwe I , Birbeck GL , 2021. Factors associated with lumbar puncture performance in Zambia. Am J Trop Med Hyg 105: 14291433.

    • Search Google Scholar
    • Export Citation
  • 10.

    Hampande ML , 2009. Attitude and Determinant of Lumbar Puncture Acceptability Among Caregivers at Three Hospitals in Zambia. Lusaka, Zambia: University of Zambia School of Medicine.

    • Search Google Scholar
    • Export Citation
  • 11.

    Deng CT , Zulkifli HI , Azizi BH , 1994. Parents’ views of lumbar puncture in children with febrile seizures. Med J Malaysia 49: 263268.

  • 12.

    Khakshour A , Hashemi M , Tavakoli H , Sheikhi Z , Kiani MA , Elmi S , 2013. Evaluation of parental attitudes toward lumbar puncture in their children. Int J Pediatr 1: 1923.

    • Search Google Scholar
    • Export Citation
  • 13.

    King MB , Rwegerera GM , 2015. An audit of consent practices and perceptions of lumbar puncture, Botswana inpatient setting experience. Afr J Emerg Med 5: 6669.

    • Search Google Scholar
    • Export Citation
  • 14.

    Alnajim SA , Al Sulaiman ZM , Al Sulaiman SM , Al Otaibi FA , Alsahfy HO , Alawami SS , Almarri NM , Sattam MA , 2017. Common misconceptions of lumbar puncture complications among parents in the Eastern Region of the Kingdom of Saudi Arabia. Int J Adv Res (Indore) 5: 12571264.

    • Search Google Scholar
    • Export Citation
  • 15.

    Narchi H , Ghatasheh G , Al Hassani N , Al Reyami L , Khan Q , 2012. Why do some parents refuse consent for lumbar puncture on their child? A qualitative study. Hosp Pediatr 2: 9398.

    • Search Google Scholar
    • Export Citation
  • 16.

    Narchi H , Ghatasheh G , Hassani NA , Reyami LA , Khan Q , 2013. Comparison of underlying factors behind parental refusal or consent for lumbar puncture. World J Pediatr 9: 336341.

    • Search Google Scholar
    • Export Citation
  • 17.

    Lindsay , 2007. UTH Dirty Secret. Lusaka Times. Lusaka, Zambia: Lusaka Times.

  • 18.

    Ling SG , Boey CC , 2000. Lumbar puncture refusal in febrile convulsion. Singapore Med J 41: 485488.

  • 19.

    Patel PB , Anderson HE , Keenly LD , Vinson DR , 2014. Informed consent documentation for lumbar puncture in the emergency department. West J Emerg Med 15: 318324.

    • Search Google Scholar
    • Export Citation
  • 20.

    Patel PB , Gilchrist A , Cronan KM , Selbst SM , 2010. Adequacy of informed consent for lumbar puncture in a pediatric emergency department. Pediatr Emerg Care 26: 739741.

    • Search Google Scholar
    • Export Citation
  • 21.

    Adityanjee , 1986. Informed consent: issues involved for developing countries. Med Sci Law 26: 305307.

  • 22.

    Creed-Kanashiro H , Ore B , Scurrah M , Gil A , Penny M , 2005. Conducting research in developing countries: experiences of the informed consent process from community studies in Peru. J Nutr 135: 925928.

    • Search Google Scholar
    • Export Citation
  • 23.

    Diemert DJ , Lobato L , Styczynski A , Zumer M , Soares A , Gazzinelli MF , 2017. A comparison of the quality of informed consent for clinical trials of an experimental hookworm vaccine conducted in developed and developing countries. PLoS Negl Trop Dis 11: e0005327.

    • Search Google Scholar
    • Export Citation
  • 24.

    Mandava A , Pace C , Campbell B , Emanuel E , Grady C , 2012. The quality of informed consent: mapping the landscape. A review of empirical data from developing and developed countries. J Med Ethics 38: 356365.

    • Search Google Scholar
    • Export Citation
  • 25.

    Newton SK , Appiah-Poku J , 2007. The perspectives of researchers on obtaining informed consent in developing countries. Developing World Bioeth 7: 1924.

    • Search Google Scholar
    • Export Citation
  • 26.

    Saleem T , Khalid U , 2009. Informed consent in developing countries: dilemmas and deliberations. J Pak Med Assoc 59: 805.

  • 27.

    Upvall M , Hashwani S , 2001. Negotiating the informed-consent process in developing countries: a comparison of Swaziland and Pakistan. Int Nurs Rev 48: 188192.

    • Search Google Scholar
    • Export Citation
  • 28.

    Walter F , Webster A , Scott S , Emery J , 2012. The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis. J Health Serv Res Policy 17: 110118.

    • Search Google Scholar
    • Export Citation
  • 29.

    Gajewski J , Mweemba C , Cheelo M , McCauley T , Kachimba J , Borgstein E , Bijlmakers L , Brugha R , 2017. Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia. Hum Resour Health 15: 53.

    • Search Google Scholar
    • Export Citation
  • 30.

    Elafros MA , Belessiotis-Richards C , Birbeck GL , Bond V , Sikazwe I , Kvalsund MP , 2022. A qualitative study of patient, caregiver, doctor and nurse views of factors influencing lumbar puncture uptake in Zambia. Trans R Soc Trop Med Hyg 116: 322327.

    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 50 50 50
Full Text Views 1122 1122 43
PDF Downloads 133 133 31
 
 
 
 
 
 
 
 
 
 
 

Patient, Provider, and Health Systems Factors Leading to Lumbar Puncture Nonperformance in Zambia: A Qualitative Investigation of the “Tap Gap”

Deanna SaylorDepartment of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
Department of Internal Medicine, University Teaching Hospitals—Adult Hospital, Lusaka, Zambia;

Search for other papers by Deanna Saylor in
Current site
Google Scholar
PubMed
Close
,
Melissa ElafrosDepartment of Neurology, University of Michigan, Ann Arbor, Michigan;

Search for other papers by Melissa Elafros in
Current site
Google Scholar
PubMed
Close
,
David BeardenDepartment of Child Neurology, University of Rochester Medical Center, Rochester, New York;

Search for other papers by David Bearden in
Current site
Google Scholar
PubMed
Close
,
Ifunanya DallahDepartment of Neurology, University of Rochester Medical Center, Rochester, New York;

Search for other papers by Ifunanya Dallah in
Current site
Google Scholar
PubMed
Close
,
Manoj MathewsDepartment of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;

Search for other papers by Manoj Mathews in
Current site
Google Scholar
PubMed
Close
,
Godfrey MuchangaMaryland Global Initiatives Corporation, Lusaka, Zambia;

Search for other papers by Godfrey Muchanga in
Current site
Google Scholar
PubMed
Close
,
Mwangala MwaleMaryland Global Initiatives Corporation, Lusaka, Zambia;

Search for other papers by Mwangala Mwale in
Current site
Google Scholar
PubMed
Close
,
Musaku MwenechanyaDepartment of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;

Search for other papers by Musaku Mwenechanya in
Current site
Google Scholar
PubMed
Close
,
Omar K. SiddiqiDepartment of Internal Medicine, University Teaching Hospitals—Adult Hospital, Lusaka, Zambia;
Global Neurology Program, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;
Center for Vaccines and Virology Research, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts;

Search for other papers by Omar K. Siddiqi in
Current site
Google Scholar
PubMed
Close
,
Peter J. WinchDepartment of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

Search for other papers by Peter J. Winch in
Current site
Google Scholar
PubMed
Close
,
Somwe wa SomweDepartment of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;

Search for other papers by Somwe wa Somwe in
Current site
Google Scholar
PubMed
Close
, and
Gretchen L. BirbeckDepartment of Neurology, University of Rochester Medical Center, Rochester, New York;
Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;
School of Medicine, University of Zambia, Lusaka, Zambia

Search for other papers by Gretchen L. Birbeck in
Current site
Google Scholar
PubMed
Close
View More View Less
Restricted access

ABSTRACT.

Lumbar puncture (LP) and cerebrospinal fluid (CSF) diagnostics are critical for evaluating central nervous system infections but are often not conducted, resulting in the “Tap Gap.” To investigate patient, provider, and health systems factors contributing to the Tap Gap in Zambia, we conducted focus group discussions with adult caregivers of hospitalized inpatients and in-depth interviews with nurses, clinicians, pharmacy workers, and laboratory staff. Transcripts were independently thematically categorized by two investigators using inductive coding. We identified seven patient-related factors: 1) alternative understandings of CSF; 2) alternative information about LPs, including misinformation; 3) mistrust of doctors; 4) consent delays; 5) fear of blame; 6) peer pressure against consent; and 7) association between LP and stigmatized conditions. Four clinician-related factors were identified: 1) limited LP knowledge and expertise, 2) time constraints, 3) delays in LP requests by clinicians, and 4) fear of blame for bad outcomes. Finally, five health systems-related factors were identified: 1) supply shortages, 2) constrained access to neuroimaging, 3) laboratory factors, 4) availability of antimicrobial medications, and 5) cost barriers. Efforts to improve LP uptake must incorporate interventions to increase patient/proxy willingness to consent and improve clinician LP competencies while addressing both upstream and downstream health system factors. Key upstream factors include inconsistently available consumables for performing LPs and lack of neuroimaging. Critical downstream factors include laboratory services that offer poor availability, reliability, and/or timeliness of CSF diagnostics and the reality that medications needed to treat diagnosed infections are often unavailable unless the family has resources to purchase privately.

Author Notes

Address correspondence to Gretchen L. Birbeck, Department of Neurology, University of Rochester Medical Center, 265 Crittenden Boulevard, CU 420694, Rochester, NY 14642. E-mail: gretchen_birbeck@urmc.rochester.edu

Authors’ addresses: Deanna Saylor, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, and Department of Internal Medicine, University Teaching Hospitals—Adult Hospital, Lusaka, Zambia, E-mail: deanna@jhmi.edu. Melissa Elafros, Department of Neurology, University of Michigan, Ann Arbor, MI, E-mail: melissa@elafros.com. David Bearden, Department of Child Neurology, University of Rochester Medical Center, Rochester, NY, E-mail: david_bearden@urmc.rochester.edu. Ifunanya Dallah, Department of Neurology, University of Rochester Medical Center, Rochester, NY, E-mail: ifunanya_dallah@urmc.rochester.edu. Manoj Mathews, Musaku Mwenechanya, and Somwe wa Somwe, Department of Pediatrics, University Teaching Hospitals—Children’s Hospital, Lusaka, Zambia, E-mails: m_s_mathew@yahoo.com, mmusaku@gmail.com, and wasomwe.uthnro@gmail.com. Godfrey Muchanga and Mwangala Mwale, Maryland Global Initiatives Corporation, Lusaka, Zambia, E-mails: muchangagodfrey@gmail.com and mwangamwale@gmail.com. Omar K. Siddiqi, Department of Internal Medicine, University Teaching Hospitals—Adult Hospital, Lusaka, Zambia, Global Neurology Program, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, and Center for Vaccines and Virology Research, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, E-mail: osiddiqi@bidmc.harvard.edu. Peter J. Winch, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: pwinch@jhu.edu. Gretchen L. Birbeck, Department of Neurology, University of Rochester Medical Center, Rochester, NY, Department of Pediatrics, University Teaching Hospitals—Children’s Hospital, Lusaka, Zambia, and School of Medicine, University of Zambia, Lusaka, Zambia, E-mail: gretchen_birbeck@urmc.rochester.edu.

Save