Greenlee JE , 1990. Approach to diagnosis of meningitis. Cerebrospinal fluid evaluation. Infect Dis Clin North Am 4: 583–598.
Scheld WM , Whitley RJ , Marra CM , 2014. Infections of the Central Nervous System. Philadelphia, PA: Wolters Kluwer Health.
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: 1771–1777.
World Health Organization , 2020. The Selection and Use of Essential In Vitro Diagnostics. Geneva, Switzerland: WHO.
World Health Organization, World Federation of Neurology , 2017. ATLAS: Country Resources for Neurological Disorders. Geneva, Switzerland: WHO.
Parry E , Godfrey R , Mabey D , Gill G , 2004. Principles of Medicine in Africa. Cambridge, UK: Cambridge University Press.
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: 7–10.
Thakur KT et al., 2015. Lumbar puncture refusal in sub-Saharan Africa: a call for further understanding and intervention. Neurology 84: 1988–1990.
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: 1429–1433.
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.
Deng CT , Zulkifli HI , Azizi BH , 1994. Parents’ views of lumbar puncture in children with febrile seizures. Med J Malaysia 49: 263–268.
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: 19–23.
King MB , Rwegerera GM , 2015. An audit of consent practices and perceptions of lumbar puncture, Botswana inpatient setting experience. Afr J Emerg Med 5: 66–69.
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: 1257–1264.
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: 93–98.
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: 336–341.
Lindsay , 2007. UTH Dirty Secret. Lusaka Times. Lusaka, Zambia: Lusaka Times.
Ling SG , Boey CC , 2000. Lumbar puncture refusal in febrile convulsion. Singapore Med J 41: 485–488.
Patel PB , Anderson HE , Keenly LD , Vinson DR , 2014. Informed consent documentation for lumbar puncture in the emergency department. West J Emerg Med 15: 318–324.
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: 739–741.
Adityanjee , 1986. Informed consent: issues involved for developing countries. Med Sci Law 26: 305–307.
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: 925–928.
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.
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: 356–365.
Newton SK , Appiah-Poku J , 2007. The perspectives of researchers on obtaining informed consent in developing countries. Developing World Bioeth 7: 19–24.
Saleem T , Khalid U , 2009. Informed consent in developing countries: dilemmas and deliberations. J Pak Med Assoc 59: 805.
Upvall M , Hashwani S , 2001. Negotiating the informed-consent process in developing countries: a comparison of Swaziland and Pakistan. Int Nurs Rev 48: 188–192.
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: 110–118.
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.
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: 322–327.
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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.
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: firstname.lastname@example.org. Melissa Elafros, Department of Neurology, University of Michigan, Ann Arbor, MI, E-mail: email@example.com. David Bearden, Department of Child Neurology, University of Rochester Medical Center, Rochester, NY, E-mail: firstname.lastname@example.org. Ifunanya Dallah, Department of Neurology, University of Rochester Medical Center, Rochester, NY, E-mail: email@example.com. Manoj Mathews, Musaku Mwenechanya, and Somwe wa Somwe, Department of Pediatrics, University Teaching Hospitals—Children’s Hospital, Lusaka, Zambia, E-mails: firstname.lastname@example.org, email@example.com, and firstname.lastname@example.org. Godfrey Muchanga and Mwangala Mwale, Maryland Global Initiatives Corporation, Lusaka, Zambia, E-mails: email@example.com and firstname.lastname@example.org. 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: email@example.com. Peter J. Winch, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: firstname.lastname@example.org. 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: email@example.com.