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The lack of adequate information about fever in low-resource settings, its unreliable self-assessment, and poor diagnostic practices may result in delayed care and under-or-overdiagnosis of diseases such as malaria. The mismatches of existing fever thermometers in the context of use imply that the diagnostic tools and connected services need to be studied further to address the challenges of fever-related illnesses and their diagnostics.
This study aims to inform a product-service system approach to design a reliable and accessible fever thermometer and connected services, as well as contribute to the identification of innovative opportunities to improve health care in low-resource settings.
To determine what factors impede febrile people seeking health care to access adequate fever diagnostics, a literature search was conducted in Google Scholar and PubMed with relevant keywords. Next, these factors were combined with a patient journey model to design a new product-service system for fever diagnostics in low-resource settings.
In total, 37 articles were reviewed. The five
Access to basic, primary health care may be enhanced with better information and technology design made through the involvement of system users.
In low-resource settings, fever-related illnesses and their diagnostics represent a particular challenge. Despite the improvements achieved through the Millennium Development Goals, more than 40% of the population of Africa, especially sub-Saharan Africa, lives in extreme poverty and suffers from high health care disparities [
The fever thermometer is one of the simplest medical devices that are widely and commonly used to support almost all kinds of everyday health care in hospitals, health care centers, physicians’ offices, ambulances, and laboratories worldwide [
The objectives of this study are to inform a systemic (ie, design) approach to develop a reliable and accessible fever thermometer and connected services, as well as to contribute to the identification of innovative opportunities to improve health care in low-resource settings [
A literature review was conducted to identify the barriers to assessing body temperature in low-resource settings. In order to clarify and quantify the relationship between fever diagnostics and a health care system, Uganda was selected as a representative country of the sub-Saharan African region. Publications were retrieved from Google Scholar and PubMed using the following keywords:
The five
In the five
The two latter aspects are often merged into one dimension. In Prahalad’s innovations in the bottom of the pyramid [
A total of 37 articles were included and reviewed. These include 25 studies that relate to treatment of febrile illnesses, of which seven address fever diagnostics and three address health care services in Uganda. Also included in the literature were four studies that looked at medical devices in low-resource settings and two studies that addressed more generally the barriers to accessing health care in low-resource settings. We identified 11 main barriers to accessing and receiving adequate fever diagnostics that were divided into the five categories (see
The difficulty and delay in accessing treatment of febrile illnesses is attributed to a large extent to the physical distance between health care providers and health care seekers. The physical distance to health care providers influences people’s choices of health care providers when seeking care for febrile illnesses. This mostly affects people living in rural areas in Uganda, where the majority of the population (84.4%) lives [
Barriers to access of diagnostics of fever-related illness.
Category | Barrier | Reference |
Accessibility | Distribution of, and distance to, health care providers | [ |
Availability | Incomplete medical infrastructure | [ |
Failure to utilize medical equipment | [ |
|
Lack of health care professionals | [ |
|
Lack of training for health care professionals | [ |
|
Poor supervision by local authorities | [ |
|
Acceptability | Cultural beliefs and influence from community members | [ |
Accommodation | Mismatch between available information and awareness, knowledge, and education needs | [ |
Lack of relevant and complete diagnostic information | [ |
|
Affordability | Cost of treatment | [ |
Cost of transport to health care provider | [ |
Public health care providers:
National referral hospital (ie, advanced tertiary care)
Regional referral hospital (ie, specialists services)
General hospital (ie, general hospital care, secondary services, laboratory, and x-ray)
Health center IV (ie, outpatients, wards, theater, laboratory, and blood transfusion)
Health center III (ie, outpatient services, maternity, general ward, and laboratory)
Health center II (ie, outpatient services only)
Health center I (ie, outpost for outreach services)
Private nonprofit health care providers:
Nongovernmental facilities
Private for-profit health care providers:
Medical clinics
Dental clinics
Drug shops
Maternity homes
Private informal health care providers:
General merchandise shops
Traditional healers
Mobile health care providers
Unqualified persons
The private health sector is categorized into private for-profit, private nonprofit, and informal providers. Drug shops categorized into private for-profit account for the largest proportion of all facilities in the private health sector in all districts except Kampala, where more clinics than drug shops can be found [
Regarding the distribution of care sought by people with febrile symptoms, 31.1% of people sought care from a health care provider. Among health providers, excluding traditional healers, the main providers visited by people with febrile symptoms were private for-profit providers (51.8%), followed by public sector (39.8%) and private nonprofit providers (8%) (see
Share of health care facilities in all of Uganda (total) and in rural Uganda [
Distribution of health care received by people with febrile symptoms [
Reasons why caretakers chose specific health care providers for fever treatment [
Among the health care facilities, public facilities are perceived as having qualified and experienced health care providers by people seeking care for fever [
Regarding staff qualification, the private sector is invariably inferior to the public sector [
Availability of thermometers at different health care provider facilities [
The distribution of health care facilities where medicine was purchased [
Besides the associated cultural beliefs regarding the subjectivity of fever itself, there are relevant acceptability aspects about how and when fever is measured among community social networks. Social networks and common practices in the communities play an important role in fever-related health care decisions. Nsungwa-Sabiiti et al [
Technologies and services do not accommodate the needs, expectations, or habits of health care seekers in several ways. First, the reading of the thermometer, as it is designed, is often not understood. This may be due to the multiplicity of different meanings people associate with fever or a febrile condition. In a setting where there is little or poor information available about the required follow-up of fever with regard to required dosages of medication and risks associated with diseases, the diagnostic information provided by the thermometer does not match the semantics associated with fever [
While the cost of treatment was a relatively minor determinant among a range of barriers to assess primary fever diagnosis compared to accessibility, the financial challenge is still one of the critical barriers and a concern for people seeking treatment for fever. The socioeconomic status of households has an effect on the timing of care seeking.
Percentage of febrile children taken outside of their home for care within 24 hours (not delayed) versus after 24 hours (delayed) in different socioeconomic quintiles [
Share of household expenditure by item group (% of total expenditure) [
This study is aimed at obtaining a comprehensive picture of the context surrounding patients and people seeking fever diagnostics in low-resource settings in order to inform a product-service system design approach and biomedical engineering approaches to fever diagnostics [
The authors propose three complementary considerations for product-service systems design of fever diagnostics: (1) the fever diagnostic patient journey to clarify the situations in which health seekers encounter barriers, (2) the different users of a fever thermometer across that journey, and (3) the different capabilities and needs of the users.
In the next sections, we will discuss these considerations in connection to the barriers to fever diagnostics as identified in the literature review.
A patient’s (and health professional’s) journey helps to identify and understand the context in which interactions between thermometers and users occur and to identify when patients experience difficulties in accessing fever diagnostics in the health care system. Since body temperatures can be taken in different situations (eg, health clinic, hospital, and household), it is important to obtain a contextual picture of users and their user tasks. In addition, it widens the scope of analysis of fever diagnostics and contributes to the identification of innovation opportunities not only by means of products (ie, fever thermometer), but also services and programs. The authors categorized the barriers into a fever diagnostics journey model (see
Barriers for assessing body temperature throughout the fever diagnostics journey.
Category | Phases and their associated barriers | ||
Awareness | Movement | Diagnostics | |
Acceptability | Cultural beliefs and influence from community members | N/Aa | N/A |
Accessibility | Mismatch between available information and awareness, knowledge, and education needs | Distribution of, and distance to, health care providers | N/A |
Availability | N/A | N/A | Incomplete medical infrastructure |
Accommodation | N/A | Lack of relevant and complete diagnostic information | N/A |
Affordability | N/A | Cost of treatment |
Cost of treatment |
aN/A: not applicable.
User groups of thermometers (left) and people who are unfamiliar with thermometers (right). Image is not proportional.
Fever diagnostics plays an important role in monitoring fever-related illnesses as well as in reverse diagnostics (ie, to confirm or discard the suspicion of disease). The availability of diagnostic confirmation at home may increase willingness to receive treatment for fever from formal health care providers and reduce the morbidity and mortality rate caused by the delay of care. The first decision of treatment at home or in the community is especially important within the context of a restrictive community where people feel pressure from others in their social network when seeking care for febrile symptoms. As such, a thermometer that is designed for the purpose of reverse diagnostics or confirmation of fever in a household should have different properties than a thermometer designed for a clinical environment. For instance, the common digital fever thermometer may be expected to be easy to use, but in fact it requires literacy and a technological mental model to be used. In a clinical setting, hygiene, complementarity with other medical devices, size, and power lifetime are very important requirements [
This study presents an outline of the barriers of access to fever diagnostics in low-resource settings. This study also discusses an approach that may lead to an improved fever thermometer and help to reveal opportunities for innovative, complementary, and holistic initiatives to improve diagnostics of fever-related illnesses. On basis of the reviewed literature focused on sub-Saharan Africa, three complementary considerations were proposed that potentially have an impact in how fever diagnostics are designed and implemented in low-resource health care systems. Firstly, the fever diagnostics journey shows the involvement of people in the different phases of diagnostics, from awareness to monitoring and follow-up. Secondly, within the same health care system, there are different users of a fever thermometer for whom the conditions of access to fever diagnostics also differ. And thirdly, these different users have different needs regarding the information that is offered. The health care system in Uganda, as in other sub-Saharan countries, is greatly divided between public and private providers, and it is clear that the choices available for communities in low-resource settings are limited. In order to improve the overall access to fever diagnostics in these settings it is important to look into the specific and potential roles and needs that the different
The outcomes of this research are currently being used as direct input for the development of a new context-based product-service system for fever diagnostics in East Africa.
not applicable
This research was supported by the Leiden-Delft-Erasmus Centre for Frugal Innovation in Africa.
None declared.