A Qualitative Study Investigating Experiences, Perceptions, and Healthcare System Performance in Relation to the Surveillance of Typhoid Fever in Madagascar


Alfred Pach, Michelle Warren, Irene Chang, Justin Im, Chelsea Nichols, Christian G. Meyer, Gi Deok Pak, Ursula Panzner, Se Eun Park, Vera von Kalckreuth, Stephen Baker, Henintsoa Rabezanahary, Jean Philibert Rakotondrainiarivelo, Tiana Mirana Raminosoa, Raphaël Rakotozandrindrainy, and Florian Marks


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 patients’ experiences and perceptions of services for febrile symptoms at the studies’ rural and urban sentinel public health clinics. The study examined influences 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 influenced delivery of care, patient access, and the health facilities’ capacity 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 findings 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.


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