A Qualitative Study Thypoid in Madagascar

7/26/2019 A Qualitative Study Thypoid in Madagascar

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Clinical Infectious Diseases

S U P P L E M E N T A R T I C L E

A Qualitative Study Investigating Experiences, Perceptions,and Healthcare System Performance in Relation to the

Surveillance of Typhoid Fever in MadagascarAlfred Pach,1 Michelle Warren,2 Irene Chang,1,3 Justin Im,1,3 Chelsea Nichols,1 Christian G. Meyer,4 Gi Deok Pak,1 Ursula Panzner,1 Se Eun Park,1Vera von Kalckreuth,1 Stephen Baker,5 Henintsoa Rabezanahary,6 Jean Philibert Rakotondrainiarivelo,6 Tiana Mirana Raminosoa,6

Raphal Rakotozandrindrainy,6 and Florian Marks1

1International Vaccine Institute, Seoul, Korea; 2University of Minnesota, Minneapolis; 3London School of Hygiene and Tropical Medicine, United Kingdom; 4Institute of Tropical Medicine,

Eberhard-Karls University Tbingen, Germany;5Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; and6University of Antananarivo, Madagascar

Background. The burden of typhoid fever (TF) in sub-Saharan Africa is largely unknown but is increasingly thought to be high,

given that water and sanitary conditions remain unimproved in many countries. To address this gap in information, the Typhoid

Fever Surveillance in Africa Program (TSAP) founded a surveillance system for TF in 10 African countries. This study was a

component of the TSAP surveillance project in Madagascar.

Methods. The study entailed a qualitative assessment of patientsexperiences and perceptions of services for febrile symptoms at

the studiesrural and urban sentinel public health clinics. The study examined inuences on the use of these facilities, alternative

sources of care, and providers descriptions of medical consultations and challenges in providing services. Data were collected

through semistructured and open-ended individual interviews and a focus group with patients, caregivers, and medical personnel.

Results. Thirty-three patients and 12 healthcare providers participated in the data collection across the 2 healthcare facilities. The

quality of services, cost, and travel distance were key factors that enabled access to and use of these clinics. Divergent healthcare-

seeking patterns were related to variability in the care utilized, socioeconomic status, and potential distance from the facilities .These

factors inuenced delivery of care, patient access, and the health facilitiescapacity to identify cases of febrile illness such as TF.

Conclusions. This approach provided an in-depth investigation and understanding of healthcare-seeking behavior at the study

facilities, and factors that facilitated or acted as barriers to their use. Our ndings demonstrate the relevance of these public health

clinics as sites for the surveillance of TF in their role as central healthcare sources for families and communities within these rural and

urban areas of Madagascar.

Keywords. typhoid fever; surveillance; healthcare utilization; illness experience.

Globally, it is estimated that there are 21.7 million new casesand 217 000 deaths associated with typhoid fever (TF) per

year [1]. TF is a systemic infection caused by the bacteriumSal-

monella enterica serovar Typhi, which is transmitted via the

oralfecal route. As a food- and water-borne infection, Salmo-

nellaTyphi causes a considerable disease burden in low-income

countries that lack safe water and adequate sanitation and hy-

giene standards [2]. The majority of our knowledge regarding

TF epidemiology arises from high-burden locations in Asia

[3]. The burden of TF in sub-Saharan Africa (SSA) is largely un-

known, but anecdotally is thought to be high, given that water

and sanitary conditions remain largely unimproved in SSAmany countries. In 2004, Crump and colleagues estimated a

moderate incidence of TF in SSA [4]; however, several more

recent population-based studies have indicated a higher inci-dence of the disease than earlier thought. During longitudinal

surveillance, S. Typhi was isolated from 6.4% of blood cultures

in an urban Kenyan surveillance site, resulting in an adjusted

incidence rate of 2243 per 100 000 among children aged 24

years. Seventy-ve percent of those S. Typhi isolates in that

study were multidrug resistant [5]. Furthermore, recent data

from Pemba Island in Zanzibar estimated an adjusted incidence

rate of 110 per 100 000 cases of TF among all age groups [6].

To address the gap in information on TF across SSA, the

Typhoid Fever Surveillance in Africa Program (TSAP), estab-

lished by the International Vaccine Institute (IVI), founded alaboratory infrastructure and surveillance system for TF and in-

vasive nontyphoidal Salmonella infections in 10 African coun-

tries. This study was a component of the TSAP surveillance

project in Madagascar coordinated by the Microbiology Labo-

ratory of Parasitology in the Faculty of Medicine at the Univer-

sity of Antananarivo, Madagascar. Disease surveillance at

sentinel healthcare facilities (HCFs) is a pragmatic way to assess

the rates and distribution of disease in any given population.

Healthcare utilization surveys support estimations of the

Correspondence: A. Pach, International Vaccine Institute, c/o 105 New England Ave,

T6 Summit, NJ 07901 ([email protected]).

Clinical Infectious Diseases 2016;62(S1):S6975

The Author 2016. Published by Oxford University Press for the Infectious Diseases Society

of America. All rights reserved. For permissions, e-mail [email protected].

DOI: 10.1093/cid/civ892

Healthcare Clinic Experience and Performance for Typhoid Fever CID 2016:62 (Suppl 1) S69
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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incidence of an illness by quantifying the use of an HCF by the

population living within a dened catchment area. A more ac-

curate measure of disease incidence can then be estimated using

the number of cases presenting to the facility adjusted by the

catchment population. However, healthcare surveys do not al-

ways capture the complexity and variability of household

healthcare-seeking behavior in response to illnesses [7]. For ex-

ample, a healthcare utilization survey for TF combining quali-

tative and quantitative data collection found that respondents inthe closed-ended survey claimed they never used traditional

forms of healing. However, in open-ended, qualitative inter-

views, respondents revealed the use of indigenous forms of

plant and household forms of healing for enteric illnesses [8].

In some cases, patients also used alternative healthcare resourc-

es, such as purchasing medications at pharmacies. Such alterna-

tive sources of care may reduce utilization of study HCFs and

affect estimates of the burden of disease [9].

The purpose of this nested TSAP study was to explore patient

perceptions of the standard of care they received at 2 sentinel

HCFs, their healthcare-seeking patterns, and their individual

reasons for use of these facilities. Providers also described the

nature of their medical consultations, the types of febrile illness-

es they see, and the challenges they face in providing care for

patients at these public health clinics. These factors inuence

delivery of care, patient access, and the health facilities capacity

to identify cases of febrile illness such as TF.

METHODS

Study Sites

Madagascar is an island country off the coast of East Africa. It has

a population of approximately 2223 million people in 2015. The

majority of its population (ie, 70%) lives in rural settings and en-

gages in agricultural activity [10]. This project was conducted in 2

HCFs in Madagascar: the Isotry Primary Healthcare Center CBS

II (ie, Centre de Sant de Base), a public health clinic in the city of

Antananarivo, and the Imeritsiatosika Primary Healthcare Center

CBS II, a rural public health clinic approximately 1 hour from An-

tananarivo. The Isotry clinic is located in an urban environment,

but draws a large proportion of its population from nearby rural

farmers who come to the city on market days to sell their crops.

Although economic disparities exist between rural and urban

populations in Madagascar, there is a high degree of similarity

in the socioeconomic and demographic characteristics betweenthe populations of the 2 HCFs.

Study Respondents

Study respondents were adults (18 years of age) who had re-

ceived medical care for a febrile disease episode affecting them-

selves or their children. The attending doctor solicited patients

participation in the interview at the end of their visit. Patients

who were not enrolled in the TSAP study were enrolled in this

substudy to avoid possible biases that may have been induced

through differential treatment provided to TSAP-enrolled pa-

tients, which may differ from the typical standard-of-care treat-

ment provided at the clinics. In addition to febrile patients,

administrative heads of the HCFs, physicians, nurses, and

nurse midwives were also interviewed using a different data col-

lection instrument. Thus, this study involved a purposive, facil-

ity-based sample of a life-experience group that had febrile

symptoms and attended the primary care study clinics. There

were also complementary key informant interviews and afocus group with the medical personnel of these facilities.

Data Collection

The interviews and focus group discussions were interactive and

exible, allowing for participants to accurately describe what they

understood and how they felt about specic issues. Discussions

were guided by a list of topics of interest. When English was

not the primary language of the respondents, a trained local inter-

viewer asked the questions and a translator summarized the con-

tent of the discussion, which allowed for follow-up questions for

clarication or elaborating on an issue. The interviews and a focus

group discussion were audio-recorded, and recorded notes weretaken throughout the course of the discussion. A total of 33 pa-

tients were interviewed, with 16 and 17 patients interviewed at

the urban and rural health care clinics, respectively. Six physicians

were interviewed: 2 at the Imeritsiatosika HFC and 4 at the Isotry

HCF. One nurse participated in an interview at the Imeritsiatosika

HFC, and 5 nurses participated in a focus group at the Isotry HCF.

The sample sizes of the patients are considered to be adequate

for a focused ethnographic study of the experience of a segment

of a population (ie, clinic attendees with febrile symptoms), es-

pecially as we conrmed these ndings in triangulating them

with the data on the healthcare providers

perspectives [11

13]. The patient sample sizes also demonstrated their adequacy

in achieving a redundancy and saturation of our analytical cat-

egories, which indicated a sufciency of information and con-

rmation of the ndings of our qualitative analysis [14].

Interview Instruments

Data collection questions for healthcare providers inquired

about several variables including patient intake at each of the

facilities, causes of fever commonly presented, tests of febrile

symptoms, how patients typically respond to fever in families,

patient beliefs, the frequency of self-treatment for fever, the

patient load and wait times at the hospital, working conditionsat the clinic, the patient referral and record system, and the cost

of medications and medical consultations.

Patient interviews involved questions on transportation and

time required to reach a facility, symptoms prompting visits to

the HCF, steps taken to manage symptoms such as self-treatment

or seeking advice from other healthcare providers, severity of

the symptoms, preferred and typical choice of care for a family

member with fever, length of wait to see a doctor, satisfaction

with the consultation, and cost of care provided.

S70 CID 2016:62 (Suppl 1) Pach et al


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Data Analysis

The interviews and focus group discussions were transcribed

and translated into English. A coding dictionary was created

based on the concepts and categories of the interview guides.

A team of 3 analysts reviewed 2 transcribed interviews each.

The analysts then coded segments of the relevant data in the in-

terviews and compared the results of the coding for comparative

reliability and completeness of the codes. Differences in coding

were discussed, and some codes were revised and others addedwhere needed. The texts of the interviews and focus groups were

then downloaded in the Ethnograph version 6 qualitative soft-

ware program and the data were coded, segmented, and ana-

lyzed for thematic content according to key topics.

Catchment Area Size and Distances to the HCFs

The measurements of the size of the catchment areas and the

distances from the villages to the Isotry and Imeritsiatosika

HCFs were calculated using Google Earth Pro. The analysis

identied the coordinates of the HCFs and the boundaries of

the catchment areas based on geographic information. The

size of the catchment area of each HFC was then calculated

with the location of the HFCs established as the study centers.

The distance from each village to its respective HFC was mea-

sured as the distance of the geographic centroid of the villages to

each HCF study center. The average of the distances of the vil-

lages to the HCFs was calculated to get the mean or average of

the distances of the villages, along with the high and low ranges

of the distances for each catchment area.

Ethical Approval

This protocol was reviewed by both the IVI Institutional Review

Board and by the Human Subjects Review Committee of theFaculty of Medicine of the University of Antananarivo. All

respondents completed a written informed consent prior to

an interview. All information was condential. All personal

identifying information was removed from the data les and

audio recordings were discarded after transcription.

RESULTS

Demography of the Participants

Sixteen interviews were conducted at the Isotry clinic in Anta-

nanarivo. Patients aged >18 years were interviewed directly,

whereas the parents of patients aged


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Healthcare Facility Experience

Experiences and perceptions of the care provided at both clinics

differed among patients, and identied reasons for the use or

nonuse of these HCFs by people in the catchment areas.

Longevity and Familiarity in the Use of the Facilities

Caregivers and patients from both Isotry and Imeritsiatosika

generally stated that patients typically have utilized these facili-

ties for a long time and have sought care for a variety of health

issues. In speaking of the Imeritsiatosika clinic, one young, fe-

male patient said, I have come here from the very beginning,

even to have my teeth taken out as a child.Similarly, a mother

of a child at the Isotry clinic recalled that my parents brought

me here as a child. I came here with my mother when I was

pregnant and I still come here when my child is sick.Thus, fa-

miliarity and regularity in the use of these clinics were men-

tioned as issues important to respondents.

Features of the Quality of Care Received

Respondents also described the quality of the care they received.

One recurrent theme was that the doctors provide medicinesthat have cured them and that the consultations and medical

tests increased their condence in the effectiveness of the care

they received. At Isotry, a mother remarked, Myrst child got

cured here and thats why I come back. As another example

of condence in the care provided, a young mother at Isotry

mentioned, According to us, we nd it safer for children and

adults . . . doctors weigh, take the temperature and size of the

child, and that makes parents like coming here.

Patients at the Imeritsiatosika clinic also appreciated the qual-

ity of the care provided. In addition, patients and parents said

that they experienced a caring and hospitable attitude on the

part of the physicians. A male patient at the Isotry clinic re-

marked, Not only are the doctors hospitable, but they respect

the patients, too. This is a state health facility where they take

care of patients, with enough time for the consultation. More-

over, patients and caregivers found that the queue was generally

not long, making it easy to see a doctor. At Imeritsiatosika, pa-

tients mentioned that it took from 2 to 30 minutes to see a doctor,

although it could be longer depending on the day. One mothers

comment at the clinic captured this attitude: It was quite easy to

see a doctor. We had to wait 15 minutes in the queue, but it was

okay . . . we had enough time to talk [to the doctor]. I am satis-

ed. These comments from these patients suggest that time towait for a doctor is an important factor in their experience of

using HCFs.

Reasons for Use of Healthcare Facilities

Illness Help-Seeking

People utilized the Isotry and Imeritsiatosika public health facil-

ities as their main source of healthcare especially when symp-

toms became painful, prolonged, or involved multiple

complaints. For instance, one mother at the Isotry clinic

described her 12-year-old childs symptoms: He had a high

temperature and when asked whats the matter? he said, I

have a sore throat, pain in the chest, and the u. He also had

a temperature and when the temperature didn t stop we came

here. Patient visits at the Imeritsiatosika HCF also often in-

volved compounded symptoms. Another mother with an 18-

month-old boy described her child s symptoms: Yesterday

after 7:30 PM after dinner he sneezed, coughed, and vomited

all the food he took. Then he couldnt breathe so well. He hada high temperature last night and with that symptom we came

here.These examples suggest that the severity of symptoms ex-

perienced can have an impact on a patients decision to seek

healthcare.

Patterns of Healthcare Use

Respondents described variations in patterns of healthcare uti-

lization related to the perceived severity of the symptoms, prac-

tices of self-care, and the use of other HCFs.

Alternative Sources of Healthcare

A number of caregivers and patients claimed to come to the

health clinics immediately when there was a fever or other ill-

ness. Yet, many individuals also described initially utilizing nat-

ural home remedies (eg, lemon and hot water) or medications

from local pharmacies to decrease symptoms before bringing a

child to see a doctor. One mother of a 12-year-old boy described

her efforts: The temperature did not go down after giving him

paracetamol, and so I brought him to the doctor.A few indi-

viduals mentioned purchasing more potent medicatio ns at

pharmacies, including Efferalgen (codeine phosphate), Niva-

quine (chloroquine sulfate), amoxicillin, and other antibiotics.

As one women patient at the Isotry clinic stated, I bought

amoxi [amoxicillin] and paracetamol because I had a sorethroat. I took 2 amoxi in the morning and 2 at night, the

same with the paracetamol . . . and I got better.Two other re-

spondents who had used antimicrobials during febrile disease

episodes also mentioned that they did not need to come to

the health clinics after they took the medication.

Healthcare providers at both clinics corroborated the com-

ments of patients. A physician at the Isotry clinic remarked

that although patients use herbs and other forms of traditional

healing, they most commonly purchase medications at local

pharmacies, including antibiotics, and do automedication at

home and come here when not cured.

This physician pointedout that this practice can lead to inadequate or incorrect use of

antibiotics and delays in proper treatment, which creates risks

for complications in cases of TF.

Respondents did not consider going to a hospital as the rst

option for primary healthcare visits. A doctor at the Isotry clinic

stated that patients have to pay for medication and tests at the

hospital, and often have to leave a family member there for

days, which can be difcult emotionally and nancially for fam-

ilies. As she said, It is impossible for poor people to go to the



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hospital because it is expensive for those in a difcult [nancial]

situation; they have to pay for the medicines and for the tests.

Another source of alternative care was the use of private clin-

ics. Use of these clinics necessitated having adequate nancial re-

sources to afford these facilities, and often a desire for a more

extended consultation with a physician. One mother at the Imer-

itsiatosika clinic described a situation that led her to visit a private

clinic. She stated that if you dont have money you go here [Im-

eritsiatosika clinic], while you can go to the private doctor whenthe money is enough. We are used to going here. But at the be-

ginning of an illness one time we gave our child paracetamol and

nivaquine but he did not improve so we brought him to the pri-

vate clinic.Another parent described the private clinics as pro-

viding more thorough and immediate care. She related

experiences in which she determined the need to go to a private

clinic: You see there are so many patients here and it takes a long

time, and you cant wait any longer because your child is ill . . .

just the medications and consultations are expensive.

Healthcare Cost and Barriers to Care

Some patients complained that they often only received the

same minor medications whenever they came to the public

health clinics; access to other medications was an incentive

for visiting a private clinic. One of the most important reasons

mentioned for coming to the public health clinics was the low

cost of the medicines they provide and that the consultations

were free. Cost was spontaneously mentioned as a reason for

utilizing the Isotry and Imeritsiatosika facilities by approximate-

ly one-third of the respondents (6/16 and 6/17 people, respec-

tively). When asked why they chose this HCF, one mother of a

patient at Imeritsiatosika said, In the rst place it is a money

problem, so that the medicines here are quite affordable.This patient considered this clinic within her means. Another

mother with her ill child at the Imeritsiatosika clinic stated

that it is near to where I live, easy to see a doctor here, and

the medication cost is cheaper.

Cost of the medications and transportation were key factors

in determining patient access to the Imeritsiatosika clinic. Pa-

tients also considered the cost of the medications at Isotry clinic

to be affordable for them. As one female patient remarked, I

like this center because the medicine is good, and cheaper com-

pared to other centers, and the doctors take care of patients.

The free consultations and inexpensive medications providedat the clinics were critical for those attending them. A doctor

at the Isotry clinic observed that most people coming to this

health facility dont have any money.

While the use of private clinics may draw individuals and care-

givers away from the use of public health clinics, a lack of funds

can act as a barrier to accessing any health facility. One female

patient at the Isotry clinic described this situation: If a child is

ill, but there is no money, you go nowhere, you suffer. An

older female patient at the Isotry clinic described the impact of

socioeconomic circumstances for her family. They should have

seen a doctor earlier this week, but couldn t come because no

money. A nurse conrmed that some families with no money

feel that it is impossible to come to a clinic and receive care de-

spite perceived need. She observed that patients dont come here

because they are afraid theyll have to pay for medications and

most people who come to the clinic dont have money.

The government of Madagascar has a social program to pro-

vide medicines for free for the very poor and elderly. If onesincome is above the cutoff or uctuates, they may not qualify

for the program. This is an incentive for the very poor to utilize

these health facilities. As a doctor at Isotry remarked, there is a

social program for people if they are poor, medication is re-

served for them . . . they dont have to pay for it.

Physicians at both clinics referred patients to hospitals with

complicated episodes of TF that did not respond to treatment. A

physician at the Isotry clinic described this situation, saying that

when a fever continues for 7 to 8 days or the individual comes

back after treatment . . . I send them to the hospital. However,

for some poor patients who are fearful of the costs at the hospital,

which they cannot afford, they avoid going to the hospital even in

cases of serious illness; as a physician at the Imeritsiatosika clinic

described, they try to treat [the illness] at home.

Overview of Healthcare-Seeking Behavior

The nurses and doctors at the Isotry and Imeritsiatosika health

clinics all agreed that there is a growing number of people com-

ing to these clinics with severe symptoms after other remedies

had failed to cure them. The head doctor at the Isotry clinic re-

marked at length on this widespread problem: Our real prob-

lem is that there are antibiotics in the stores, and now there is

ibuprofen which people do take. They only come here whentheir children and family do not get better. So patients are

often exhausted and have temperatures which they cannot re-

duce, so thats why they say that they have been ill for 2 or 3

days before coming here. This behavior represents a serious

problem for surveillance at the clinics. Accounting for varying

patterns of healthcare utilization and barriers to the use of these

clinics is a challenge in conducting effective surveillance. An-

other physician at Imeritsiatosika also observed that if a child s

fever is prolonged, serious, and not responding to treatment at

home, it can increase the potential for complications.

DISCUSSION

These accounts of healthcare-seeking behaviors of patients and

healthcare providers demonstrate factors that have implications

for conducting surveillance on febrile illness. Healthcare utiliza-

tion surveys are necessary tools for adjusting estimations of the

incidence of disease via passive surveillance at clinics. However,

this study suggests that there are selective factors related to both

the clinics and patient behaviors that can facilitate or limit use

of these clinics by certain subpopulations. Yet, several features



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of these clinics make them critical sites for the surveillance of

enteric fever in Madagascar. A number of patients said that

they had utilized these clinics throughout their life and contin-

ued to access them for their children, especially for prolonged or

serious symptoms such as those that characterize TF. The ma-

jority of respondents attributed the regular use of these HCFs to

the high-quality care that they received at these clinics. They ap-

preciated the recording of vital signs at each visit, which added

to the information available to physicians, and were very satis-ed with their consultations and the wait time to see a doctor. It

is important to note that a majority of patients walked to the

clinics from nearby communities, although this may limit pa-

tients from distant communities or those who are very sick

from attending these HCFs.

Both patients and healthcare providers observed that patients

generally sought care for themselves or their children when

fever was severe, prolonged, or complicated with other symp-

toms and often attempted to self-treat prior to making a visit

to the clinic. Consequently, patients with mild and perhaps

moderate cases of febrile illness may not present as regularly

to these clinics as do those with more serious conditions. More-

over, adult men accounted for a small proportion of fever cases

seen at the Isotry and Imeritsiatosika clinics. One nurse ob-

served that men rarely come to the HCF unless they are very

ill. This might be because of the opening hours that overlap

with the workday. Differential health-seeking behaviors be-

tween sexes and age groups may bias incidence estimates

based on sentinel surveillance, as well as whether disease is dif-

ferentially distributed among these groups.

We noted that the cost of treatment at these HCFs encour-

aged or discouraged attendance depending on the respondent s

socioeconomic status. Some respondents who did not have gov-ernment-subsidized healthcare registration due to being above

the income cutoff designation described instances when their

nancial status prevented them from visiting the clinic despite

a perceived need for care, whereas those with lower incomes

were able to receive free treatment. Respondents with a higher

socioeconomic status also reported using private clinics if they

felt that the public health clinic could not meet their needs.

Therefore, the poor and wealthy may be diverted from the sur-

veillance sites during episodes of febrile illness, though the caus-

es and avenues of diversion differ. Research on healthcare

utilization in general, and for TF speci

cally, shows that satis-faction with healthcare services, cost, and distance to health fa-

cilities are key factors in determining their use [1517].

A method to address loss of cases to other facilities in surveil-

lance at sentinel sites has been to provide incentives to private

clinics to record enteric illnesses and provide these data to study

investigators [18]. Another approach may be to reach distant

and marginal populations and increase utilization of HCFs by

complementing attendance with a mobile phone component

to the passive surveillance, in which households are incentivized

to call a clinic in the case of fever. When indicated, a paramedic

could be dispatched to the home of the patient to take blood

samples for laboratory assessments and case identication,

thus augmenting passive surveillance [1920].

There were both limitations and strengths to this study. This

study involved a small and purposive sample of patients, nurses,

and doctors that came to and were present at these HCFs during

a 6-week period, which limits overall study generalizability. In

addition, data collection involved qualitative interviews andfocus groups, which did not measure the frequency or distribu-

tion of responses in a representative sample of the whole pop-

ulation of the catchment areas. However, the study gathered

information from an adequate sample of respondents for an

in-depth appraisal of febrile patient and caregiver perceptions

of and experience with the Imeritsiatosika and Isotry clinics

that demonstrated general agreement on their experiences and

rationale for the use of these facilities among patient respon-

dents, which was corroborated in interviews with healthcare

providers.

CONCLUSIONS

This qualitative study of 2 sentinel public health clinic surveil-

lance sites in Madagascar provides an in-depth perspective on

healthcare-seeking behaviors and experiences related to impor-

tant contextual and patient-centered experiences. This informa-

tion is useful for augmenting health utilization survey research

and disease surveillance efforts. It was critical to account for the

use and experience of these key health facilities, as well as var-

iation in their use, in relation to the perceived quality of the ser-

vices, the rationale for the use of alternative sources of care, and

the geographic and socioeconomic factors that inuenced re-

sponses to cases of febrile symptoms. This study demonstratesthe importance of these 2 clinics as sites for the surveillance of

enteric fever in their role as central healthcare sources for fam-

ilies and communities from this area of Madagascar.

Notes

Acknowledgments. The authors thank the patients and families of those

who participated in this study for their cooperation, which made this work

possible. We also express our gratitude to the staff at the Isotry and Imerit-

siatosika clinics for providing important information and for theirassistance

in organizing patients and caregivers for interviews.

Financial support. This research was funded by the Bill & Melinda

Gates Foundation (grant number OPPGH5231), and this publication was

made possible through a grant from the Bill & Melinda Gates Foundation

(OPP1129380).

Supplement sponsorship. This article appears as part of the supplement

Typhoid Fever Surveillance in Africa Program (TSAP),sponsored by the

International Vaccine Institute.

Potential conicts of interest. All authors: No reported conicts. All

authors have submitted the ICMJE Form for Disclosure of Potential Con-

icts of Interest. Conicts that the editors consider relevant to the content

of the manuscript have been disclosed.

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A Qualitative Study Thypoid in Madagascar