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The rapid increase in chronic non-communicable diseases (NCDs) poses a major challenge to already strained health systems in sub-Saharan Africa. This study investigates the factors associated with seeking and receiving NCD services in Tanzania, using a household survey and client exit interview data from Kilombero and Same districts. Both districts are predominantly rural, with one semi-urban area called Ifakara town and Same town. Of the 784 household survey respondents, 317 (40.4%), 37 (4.7%), and 20 (2.5%) were diagnosed with hypertension, diabetes mellitus, and other NCDs, respectively, of whom 69% had sought care in the past six months. After controlling for covariates, those enrolled in the National Health Insurance Fund (NHIF) and those who received a user fees waiver were more likely to use health services. However, even when NCD patients managed to access the care they needed, they were likely to receive incomplete services. The main reason for not receiving all services at the health facility visited on the day of the survey was drug stock-outs. Among health care users, those registered with the improved Community Health Funds (iCHF) were less likely to receive all prescribed services at the health facility visited than uninsured patients. The findings of this study highlight the need to strengthen both primary care and social health protection systems to improve access to needed care for NCD patients. [ABSTRACT FROM AUTHOR]

Objective: People commonly cope with chronic low back pain (cLBP) by ignoring and distraction. Can mindful interoceptive exposure to the pain sensation itself and its phenomenological components be an alternative approach? Methods: Single-arm feasibility study in patients with cLBP using a 2-minute attention exercise guided by a smartphone app several times per day over 8 weeks. We assessed feasibility, pre/post pain, function, and psychological parameters using mixed methods: standard questionnaires, ecological momentary assessment, and exit interviews that included micro-phenomenology technique and subsequent reflexive thematic qualitative analysis. Results: We enrolled 31 participants, mostly female, mean age 48, the majority had pain for >5 years; 29 completed. Mean pain intensity [0–10] improved from 4.8 ±1.7 to 3.1 ±1.9 (p <.0001); mean PEG scores (intensity and interference with daily life; range 0–30) improved from 13.7 ±6.2 to 8.4 ±6.6 (p <.0001); pain impact (9 items incl physical function) 22.3 ±8.7 to 19.7 ±8.1 (p =.0010). Twenty-one of 29 improved PEG score ≥30%. There were significant improvements in PCS Rumination and MAIA Not-Worrying. Participants became aware of their usual habit of avoidance and the challenge of and resistance to focusing on pain. They were surprised how pain sensations varied over time, and that pain intensity and the threat value of pain could diminish by focusing on it. They described a variety of 3D pain shapes (e.g., football, pool ball, rod, nail, brick, stars) with a range of colors, transparency, temperature, and density that for some changed with mindful attention. Most struggled to find appropriate words for sensory awareness and attention regulation and found that the threat value of their pain diminished. Conclusions: Mindful interoceptive exposure to the sensations of their cLBP using a 2-minute attention exercise with a phone app—rather than ignoring and distracting from it—may be a beneficial intervention for cLBP. Trial registration: ClinicalTrials.gov #NCT06186193. [ABSTRACT FROM AUTHOR]

Introduction: Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. Methods: Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. Results: Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52–1.01] and 0.83 [95%CI: 0.63–1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71–1.32]). Conclusions: Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention. [ABSTRACT FROM AUTHOR]

A retrospective facility-based costing study was undertaken to estimate the comparative cost per visit of five integrated sexual and reproductive health and HIV (human immuno-deficiency virus) services (provider perspective) within five clinic sites. These five clinics were part of four service delivery models: Non-governmental-organisation (NGO) directly managed model (Chitungwiza and New Africa House sites), NGO partner managed site (Mutare site), private-public-partnership (PPP) model (Chitungwiza Profam Clinic), and NGO directly managed outreach (operating from New Africa House site. In addition client cost exit interviews (client perspective) were conducted among 856 female clients exiting integrated services at three of the sites. Our costing approach involved first a facility bottom-up costing exercise (February to April 2015), conducted to quantify and value each resource input required to provide individual SRH and HIV services. Secondly overhead financial expenditures were allocated top-down from central office to sites and then respective integrated service based on pre-defined allocation factors derived from both the site facility observations and programme data for the prior 12 months. Costs were assessed in 2015 United States dollars (USD). Costs were assessed for HIV testing and counselling, screening and treatment of sexually transmitted infections, tuberculosis screening with smear microscopy, family planning, and cervical cancer screening and treatment employing visual inspection with acetic acid and cervicography and cryotherapy. Variability in costs per visit was evident across the models being highest for cervical cancer screening and cryotherapy (range: US$6.98—US$49.66). HIV testing and counselling showed least variability (range; US$10.96—US$16.28). In general the PPP model offered integrated services at the lowest unit costs whereas the partner managed site was highest. Significant client costs remain despite availability of integrated sexual and reproductive health and HIV services free of charge in our Zimbabwe study setting. Situating services closer to communities, incentives, transport reimbursements, reducing waiting times and co-location of sexual and reproductive health and HIV services may help minimise impact of client costs. [ABSTRACT FROM AUTHOR]

The purpose of this study was to analyze secondary resiliency and user experience outcomes from a novel, 8-week website-based mind-body intervention (NF-Web) for adults (18+) with neurofibromatosis (NF1, NF2, and schwannomatosis), a genetic, neurocutaneous disorder characterized by nerve sheath tumors of the central and peripheral nervous system. The study design was a secondary data analysis of a single-arm, early feasibility pilot study (September 2020-May 2021) for adults with NF (N = 28). Across participants, the mean age was 46 (SD = 13.67) and included 22 females and 6 males. Participants completed baseline and posttest assessments (t-tests), as well as exit interviews (exploratory rapid data analysis). Results demonstrated that participation was associated with pre-to-post improvements in gratitude, coping, and mindfulness (p <.05). Exit interviews indicated participant enjoyment and that many would recommend NF-Web to a friend. Participants found the website easy to navigate and enjoyed NF-Web's video format. Many found transcripts useful if they had hearing differences or if English was their second language. NF-Web demonstrated initial signals of improvement in resiliency outcomes and positive user experience. Future pilot RCTs will explore these changes by NF type. [ABSTRACT FROM AUTHOR]

Longitudinal, community-based sampling is important for understanding prevalence and transmission of respiratory pathogens. Using a minimally invasive sampling method, the FAMILY Micro study monitored the oral, nasal and hand microbiota of families for 6 months. Here, we explore participant experiences and opinions. A mixed methods approach was utilised. A quantitative questionnaire was completed after every sampling timepoint to report levels of discomfort and pain, as well as time taken to collect samples. Participants were also invited to discuss their experiences in a qualitative structured exit interview. We received questionnaires from 36 families. Most adults and children >5y experienced no pain (94% and 70%) and little discomfort (73% and 47% no discomfort) regardless of sample type, whereas children ≤5y experienced variable levels of pain and discomfort (48% no pain but 14% hurts even more, whole lot or worst; 38% no discomfort but 33% moderate, severe, or extreme discomfort). The time taken for saliva and hand sampling decreased over the study. We conducted interviews with 24 families. Families found the sampling method straightforward, and adults and children >5y preferred nasal sampling using a synthetic absorptive matrix over nasopharyngeal swabs. It remained challenging for families to fit sampling into their busy schedules. Adequate fridge/freezer space and regular sample pick-ups were found to be important factors for feasibility. Messaging apps proved extremely effective for engaging with participants. Our findings provide key information to inform the design of future studies, specifically that self-sampling at home using minimally invasive procedures is feasible in a family context. [ABSTRACT FROM AUTHOR]

Introduction: Unlike household surveys, client exit interviews are conducted immediately after a consultation and therefore provides an opportunity to capture routine performance and level of service quality. This study examines the validity and reliability of women's reports on selected ANC interventions in exit interviews conducted in Malawi. Methods: Using data from the 2013–2014 Malawi service provision facility census, we compared women's reports in exit interviews regarding the contents of ANC received with reports obtained through direct observation by a trained healthcare professional. The validity of six indicators was tested using two measures: the area under the receiver operating characteristic curve (AUC), and the inflation factor (IF). Reliability of women's reports was measured using the Kappa coefficient (κ) and the prevalence-adjusted bias-adjusted kappa (PABAK). Finally, we examined whether reporting reliability varied significantly by individual and facility characteristics. Results: Of the six indicators, two concrete and observable measures had high reporting accuracy and met the validity criteria for both AUC ≥ 0.7 and 0.75>IF>1.25, namely whether the provider prescribed or gave malaria prophylaxis (AUC: 0.84, 95% CI: 0.83–0.86; IF: 0.96) or iron/folic tablets (AUC: (0.84 95% CI: 0.81–0.87; IF:1.00). Whereas four measures related to counselling had lower reporting accuracy: whether the provider offered counselling about nutrition in pregnancy (AUC: 0.69, 95%CI: 0.67–0.71; IF = 1.26), delivery preparation (AUC: 0.62, 95% CI: 0.60–065; IF = 0.99), pregnancy related complications (AUC: 0.59, 95%CI: 0.56–0.61; IF = 1.11), and iron/folic acid side effects (AUC:0.58, 95% CI: 0.55–0.60; IF = 1.42). Similarly, the observable measures had high reliability with both κ and PABAK values in the ranges of ≥ 0.61 and ≥ 0.80. Respondent's age, primiparous status, number of antenatal visits, and the type of health provider increased the likelihood of reporting reliability. Conclusion: In order to enhance the measurement of quality of ANC services, our study emphasizes the importance of carefully considering the type of information women are asked to recall and the timing of the interviews. While household survey programmes such as the demographic health survey and multiple indicator cluster survey are commonly used as data sources for measuring intervention coverage and quality, policy makers should complement such data with more reliable sources like routine data from health information systems. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization recommended the Test, Treat and Track (T3) strategy for malaria control that, every suspected malaria case should be tested prior to treatment with Artemisinin-based combination therapy (ACT) and tracked. We assessed the performance and challenges in the implementation of T3 strategy among children under-five years in Volta and Oti Regions of Ghana. Method: A descriptive cross-sectional study was carried in 69 health facilities. Exit interviews were conducted for caregivers of children with fever using a semi-structured questionnaire. Clinicians were interviewed at the out-patient department in each facility. Descriptive statistics was conducted, Chi-square test and logistic regression were used to determine the associations between completion of T3 and independent variables. Results: Most children, 818/900 (90.9%) were tested for malaria and 600/818 (73.4%) were positive for malaria parasitaemia using rapid diagnostic test. Of those testing positive for malaria, 530/600 (88.3%) received treatment with ACTs. Half, (109/218) of the children testing negative for malaria also received ACTs. Also, 67/82 (81.7%) of children not tested for malaria received ACTs. Only 408/900 (45.3%) children completed T3 with Community Health-based Planning Services (CHPS) compound having the highest completion rate 202/314 (64.3%). CHPS Compounds were 6.55 times more likely to complete T3 compared to the hospitals [(95% CI: 3.77, 11.35), p<0.001]. Health facilities with laboratory services were 2.08 times more likely to complete T3 [(95% CI: 1.55, 2.79), p<0.001] The main challenge identified was clinicians' perception that RDTs do not give accurate results. Conclusion: Testing fever cases for malaria before treatment and treating positive cases with ACTs was high. Treating negative cases and those not tested with ACTs was also high. Health facilities having laboratory services and facility being CHPS compounds were key predictors of completing T3. Clinician's not trusting RDT results can affect the T3 strategy in malaria control. Periodic training/monitoring is required to sustain adherence to the strategy. [ABSTRACT FROM AUTHOR]

People living with HIV (PLWH) on antiretroviral therapy (ART) are living longer and are at risk of HIV co-morbidities including non-communicable diseases (NCDs), particularly in low-resource settings. However, the evidence base for effectively integrating HIV and NCD care is limited. The Chronic Health Care (CHC) checklist, designed to screen for multiple NCDs including a 6-item diabetes self-report screener, was implemented at two PEPFAR-supported HIV clinics in Kabwe and Kitwe, Zambia. Study objectives were to describe the HIV care and treatment population and their self-reported diabetes-related symptoms, and to evaluate provider-initiated screening and referral post-training on the CHC checklist. This cross-sectional study enrolled 435 adults receiving combination ART services. Clinic exit interviews revealed 46% self-reported at least one potential symptom, and 6% self-reported three or more symptoms to the study team, indicating risk for diabetes and need for further diagnostic testing. In comparison, only 8% of all participants reported being appropriately screened for diabetes by their health provider, with less than 1% referred for further testing. This missed opportunity for screening and referral indicates that HIV-NCD integration efforts need more fully resourced and multi-pronged approaches in order to ensure that PLWH who are already accessing ART receive the comprehensive, holistic care they need. [ABSTRACT FROM AUTHOR]

Background: Despite efforts to contain the spread of COVID-19, Addis Ababa, the country's COVID-19 epicenter, is experiencing a sharp increase in the number of cases and death rate. While poor public adherence to COVID-19 precautionary practices is evident, factors associated with it are not well studied. We aimed to assess the level of practice of COVID-19 precaution and associated factors. Methods: This was a hospital-based cross-sectional study conducted from February 1st to 15th, 2021 at Saint Paul's Hospital Millennium Medical College, a tertiary teaching hospital in Addis Ababa, Ethiopia. We used a structured questionnaire to conduct a face-to-face exit interview with clients visiting the hospital. Systematic random sampling was employed to recruit study participants. Binary and multivariable logistic regressions were implemented to examine factors associated with precautionary practices. Statistical significance was declared at p-value <0.05. The Crude odds ratio (COR) and Adjusted odds ratio (AOR) were reported with a 95% confidence interval. Results: We analyzed data obtained from 262 participants. The mean age of participants was 36 (SD+12) years. The majority (207, 79%) of the study participants had a favorable attitude towards prevention and control measures of COVID-19. A little over half (116, 55.7%) of the respondents had a satisfactory level of practice of COVID-19 precautions. Living in an area with strict enforcement of COVID-19 precautionary measures [AOR: 2.25, 95% CI (1.22–4.15)], and having a favorable attitude of COVID-19 prevention [AOR: 4.88, 95% CI (2.08–11.68)] were significantly associated with satisfactory COVID-19 precautionary practices. Conclusions: The level of practice of COVID-19 precaution was unsatisfactory. Favorable attitude and stricter enforcement of COVID-19 preventive measures might have contributed more to adherence to precautionary practices. The findings highlight the need for a public health education strategy targeted at improving attitudes of the community on COVID-19 focusing on the effectiveness of preventive measures. [ABSTRACT FROM AUTHOR]

Background: Medication counselling is an important activity that improves patient therapeutic outcomes. After this activity has been carried out, patients should be satisfied with counselling, and possess adequate knowledge about their medications. Objectives: To describe outpatient/caregiver medication knowledge and satisfaction with medication counselling at the main outpatient pharmacies of eight public secondary and tertiary hospitals located in two states in Northwestern Nigeria. Methods: Exit interviews were conducted from December 2019 to March 2020 with randomly sampled patients/caregivers who had just been dispensed one or more prescription medications from the main pharmacies of the hospitals. The questionnaire used contained 31 questions in three sections. The first section collected demographic information. The second section assessed respondents' experiences and overall satisfaction with the counselling they had received. The last section evaluated respondents' knowledge of one randomly selected prescription medication that had been dispensed to them. Data collected were coded and analyzed to generate descriptive statistics. To explore associations between respondent characteristics and overall satisfaction, non-parametric tests were used, and statistical significance set at p<0.05. Results: A total of 684 patients/caregivers were interviewed. Majority of respondents agreed that the time spent (97.1%) and quantity of information (99.1%) provided during counselling was adequate. However, over 60% of them also agreed that dispensers did not assess their understanding of information provided or invite them to ask questions. Despite this, their average overall satisfaction with counselling on a 10-point scale was 8.6 ± 1.6. Over 90% of them also correctly identified the routes and frequency of administration of the prescribed medication selected for the knowledge assessment. Although, more than 60% of respondents did not know the duration of therapy or names of these medications. Conclusion: Respondents' satisfaction with medication counselling was fairly high even though they did not seem to know much about their medication. [ABSTRACT FROM AUTHOR]

Background: Available evidence suggests that provision of quality of care in family planning services is crucial to increasing uptake and continuation of use of contraception. Kenya achieved a modern contraceptive prevalence rate of 60% in 2018, surpassing its 2020 target of 58%. With the high prevalence, focus is geared towards improved quality of family planning services. The objective of this study is to examine the quality of family planning counseling and its associated factors in health facilities in Kenya. Methods: We conducted a secondary analysis of the 2019 Kenya Performance Monitoring and Action, client exit data of women who had received family planning services. Quality of counseling was assessed using the Method Information Index Plus. We conducted a multivariable ordinal logistic regression analysis of data from 3,731 women to establish determinants of receiving quality family planning services. Results: The Method Information Index Plus score for higher-quality counseling was 56.7%, lower-quality counseling 32.4%, and no counseling 10.9%. Women aged 15–24 years (aOR = 0.69, 95% CI = 0.56–0.86, p = 0.001) had lower odds of receiving better counseling compared to women aged 35 years and above. Those with no education (aOR = 0.52, 95% CI = 0.33–0.82, p = 0.005), primary (aOR = 0.56, 95% CI = 0.44–0.71, p<0.001) and secondary (aOR = 0.79, 95% CI = 0.65–0.98, p = 0.028) were less likely to receive better counseling compared to those with tertiary education. Women who received long acting and reversible contraception methods (aOR = 1.75, 95% CI = 1.42–2.17, p<0.001), and those who were method switchers (aOR = 1.24, 95% CI = 1.03–1.50, p = 0.027), had a higher likelihood of receiving better quality of counseling as compared to those on short-term methods and those who were continuers, respectively. Conclusion: The quality of family planning counseling in Kenya is still sub-optimal considering that some women receive no form of counseling at service delivery point. There is need to review the existing FP guidelines and training packages to increase focus on the quality of counseling services offered by health providers. Social accountability strategies that empower women to demand quality services should be included in community-level family planning interventions. [ABSTRACT FROM AUTHOR]

Background: This study aimed to help the Namibian government understand the impact of Treat All implementation (started on April 1, 2017) on key antiretroviral therapy (ART) outcomes, and how this transition impacts progress toward the UNAIDS's 90-90-90 HIV targets. Methods: We collected clinical records from two separate cohorts (before and after treat-all) of ART patients in 10 high- and medium-volume facilities in 6 northern Namibia districts. Each cohort contains 12-month data on patients' scheduled appointments and visits, health status, and viral load results. We also measured patients' wait time and perceptions of service quality using exit interviews with 300 randomly selected patients (per round). We compared ART outcomes of the two cohorts: ART initiation within 7 days from diagnosis, loss to follow-up (LTFU), missed scheduled appointments for at least 30 days, and viral suppression using unadjusted and adjusted analyses. Results: Among new ART clients (on ART for less than 3 months or had not yet initiated treatment as of the start date for the ART record review period), rapid ART initiation (within 7 days from diagnosis) was 5.2 times higher after Treat All than that among clients assessed before the policy took effect [AOR: 5.2 (3.8–6.9)]. However, LTFU was higher after Treat All roll-out compared to before Treat All [AOR: 1.9 (1.3–2.8)]. Established ART clients (on ART treatment for at least three months at the start date of the ART record review period) had over 3 times greater odds of achieving viral suppression after Treat All roll-out compared to established ART clients assessed before Treat All [AOR: 3.1 (1.6–5.9)]. Conclusions and recommendations: The findings indicate positive effect of the "Treat All" implementation on ART initiation and viral suppression, and negative effect on LTFU. Additionally, by April 2018, Namibia seems to have reached the UNAIDS's 90-90-90 targets. [ABSTRACT FROM AUTHOR]

Background: Poor knowledge concerning appropriate antibiotic use significantly influences the misuse of antibiotics within the community, especially in developing countries where there are weaker health systems to regulate antibiotic dispensing. Antibiotic misuse leads to antibiotic resistance. This study assessed knowledge of appropriate antibiotic use among buyers in the Moshi municipality, Northern Tanzania. Methods: We conducted a cross-sectional study in Moshi municipality between April and May 2017. Adults who bought antibiotics at drug outlets were invited to participate in the study. An exit interview was conducted with participants to collect their demographics and assess their knowledge concerning appropriate use of antibiotics. A logistic regression model was performed to determine factors associated with correct knowledge concerning antibiotic use. Results: A total of 152 adults with a median age of 30.5 (IQR 25–42) years, were enrolled in the study. Slightly over half (n = 89, 58.6%), responded that they should stop antibiotics after finishing the dose as directed. Half (n = 77, 50.7%) thought that it was acceptable to share antibiotics with other individuals and over half of respondents (n = 95, 65.1%) thought that they should request the same antibiotics if they had used them to treat a similar illness in the past. Only 38 (25%) had adequate knowledge about the use of antibiotics. Sore throat and flu were respectively identified by 62.5% and 46.1% of respondents as conditions that can be treated with antibiotics. Higher levels of education (aOR = 4.11 95%CI = 1.44–11.71) and having health insurance (aOR = 9.05 95%CI = 3.35–24.45) were associated with better levels of knowledge concerning antibiotic use in various illnesses. Conclusion: There is inadequate knowledge concerning the indications for antibiotics and their appropriate usage. Health promotion campaigns are needed to educate the population about appropriate antibiotic use and reduce their irrational use. [ABSTRACT FROM AUTHOR]

Background: Malaria data reported through Mozambique's routine health information system are used to guide the implementation of prevention and control activities. Although previous studies have identified issues with the quality of aggregated data reported from public health facilities in the country, no studies have evaluated the quality of routine indicators recorded in health facility registries. This study addresses this issue by comparing indicators calculated from data from exit interviews and re-examinations of patients with data based on registry records from health facilities in order to measure the quality of registry data and data reporting in three provinces in Mozambique. Methods: Data were collected from 1,840 outpatients from 117 health facilities in Maputo, Zambézia, and Cabo Delgado Provinces interviewed and examined as part of a malaria-specific health facility survey. Key indicators based on exit interview / re-examination data were compared to the same indicators based on records from health facility registries. Multivariable regression was performed to identify factors associated with indicators matching in re-examination / exit interview data and health facility registries. Aggregated indicators abstracted from facility registries were compared to those reported through the routine health management information system (HMIS) for the same time period. Results: Sensitivity of exit interview / re-examination data compared with those recorded in facility registries was low for all indicators in all facilities. The lowest sensitivities were in Maputo, where the sensitivity for recording negative RDT results was 9.7%. The highest sensitivity was for recording positive RDT results in Cabo Delgado, at 75%. Multivariable analysis of factors associated with agreement between gold standard and registry data showed patients were less likely to be asked about having a fever in the triage ward in Maputo and Cabo Delgado (adjusted Odds Ratio 0.75 and 0.39 respectively), and in the outpatient ward in Cabo Delgado (aOR = 0.37), compared with the emergency department. Patients with positive RDT were also more likely to have RDT results recorded in all three provinces when patients had been managed according to national treatment guidelines during initial examination. Comparison of retrospective data abstracted from facility registries to HMIS data showed discrepancies in all three provinces. The proportion of outpatient cases with suspected and confirmed malaria were similar in registry and HMIS data across all provinces (a relatively low difference between registry and HMIS data of 3% in Maputo and Zambézia), though the total number of all-cause outpatient cases was consistently higher in the HMIS. The largest difference was in Maputo, where a total of 87,992 all-cause outpatient cases were reported in HMIS, compared with a total of 42,431 abstracted from facility registries. Conclusion: This study shows that care should be taken in interpreting trends based solely on routine data due to data quality issues, though the discrepancy in all-cause outpatient cases may be indicative that register availability and storage are important factors. As such, simple steps such as providing consistent access and storage of registers that include reporting of patient fever symptoms might improve the quality of routine data recorded at health facilities. [ABSTRACT FROM AUTHOR]