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

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

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Melissa Elafros Department of Neurology, University of Michigan, Ann Arbor, Michigan;

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David Bearden Department of Child Neurology, University of Rochester Medical Center, Rochester, New York;

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Ifunanya Dallah Department of Neurology, University of Rochester Medical Center, Rochester, New York;

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Manoj Mathews Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;

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Godfrey Muchanga Maryland Global Initiatives Corporation, Lusaka, Zambia;

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Mwangala Mwale Maryland Global Initiatives Corporation, Lusaka, Zambia;

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Musaku Mwenechanya Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;

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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, Massachusetts;
Center for Vaccines and Virology Research, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts;

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Peter J. Winch Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;

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Somwe wa Somwe Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia;

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Gretchen L. Birbeck Department 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

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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.

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