ACTs have become the first-line treatment and the large-scale use is assured by the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund in short), which has led to a much higher use in most endemic areas over the past decade despite the relatively high costs of these drugs. Inaccurate and/or delayed diagnosis led to an overconsumption of antimalarial that can also contribute to the development and spread of drug resistance
. The introduction of RDTs significantly reduces these risks
 and provides a unique opportunity to render the approach of prompt diagnosis and treatment at peripheral level, i.e. the point-of-care, more effective
. Clearly, the use of RDT has opened up new ways for adequate case management. However, acceptance of RDTs still remains an issue for many endemic areas, as rural populations do not necessarily agree having their blood tested even for RDTs for malaria. Currently, little is known about social, cultural and religious factors governing people’s attitudes and behaviour that govern acceptance of RDTs.
Our study, undertaken in a rural part of central Côte d’Ivoire, revealed specific local concepts with regard to the perception of blood, blood-related diseases and having blood tested with an RDT. Interestingly, the majority of people from Bozi were unwilling to have an RDT for malaria done that was provided free of charge, but this was somewhat influenced by educational attainment. Indeed, unlike Bozi, the majority of household heads in Yoho had attended at least primary school. Moreover, the percentage of children from mothers with at least primary education was higher in Yoho
. According to our questionnaire survey, people believe that they know the manifestations of clinical symptoms due to malaria, and hence they do not see the necessity for an RDT prior to start with treatment. Patients from Bozi and Yoho were aware of some of the dangers posed by malaria. However, based on direct observation by our research team, residents from Bozi largely negated help-seeking as they perceived the quality of care as low. Since Yoho inhabitants paid for transportation to get to the Bozi health centre, it seems conceivable that they seek care for only serious conditions. In contrast, free testing with an RDT for malaria and access to drugs increased their willingness to do the exams. In addition, the user-provider interactions are crucial as also observed in a study in Ghana investigating the relationship between health workers and patients
. Malaria can be easily treated when promptly diagnosed but owing to people’s perceptions and beliefs, several barriers still exist as indicated by this and many other studies. Two key determinants are, first, inappropriate self-medication with medicinal plants or inappropriate medicine
 and, second counterfeit or substandard medicines as revealed in studies from Nigeria
Therapies from health centres and traditional healers were used together, showing an interest to modern medicine mixed with more traditional remedies. For the group of people who were unwilling to have malaria RDTs done, it was their belief that, traditional healers provided good and clear diagnosis of the disease. Therefore, visiting a health centre would mean to have modern drugs that will speed up their recovery.
There were various opinions from our surveys which contributed to a deeper understanding of the attitudes and behaviours of Yoho and Bozi populations with regard to RDTs for malaria. The introduction of RDTs was clearly affected by the different levels of acceptability owing to the innovative nature of this diagnostic tool and its use at different levels of the health care delivery systems. People linked their reluctance to previous experiences with blood taking and use. For instance, blood would also be used for other occult practices such as bewitching and fetishisms, among others. For people, blood was considered a sacred biofluid and the source of life. It cannot be used anyhow except when asked purposely for medical testing. This is the reason why, some people in the study area were compliant to accept RDTs for malaria, but not for other diseases. By contrast there was also another group of people who believed that for a disease like malaria, there is no need to do a diagnostic test because the signs were sufficient to confirm the idea that the disease (especially malaria) “is not in the blood”. Traditional representations did influence the acceptance of RDTs for malaria. One of these representations was the feeling to have the best treatment against malaria. According to their opinion, the best treatment against malaria did not require the use of blood unlike malaria RDTs. Thus, the local concepts of malaria as a disease do have a considerable influence on malaria management
Acceptability of RDTs was also governed by the level of perceived fear. Interviewed persons expressed their fear based on the pain caused by the needle prick, but also other fears, particularly that blood samples would be utilized for checking their HIV status instead of malaria. Indeed, we found a high rate of people who refused to have an RDT performed for malaria, which might be explained by the fact that before introducing malaria RDTs at the health centre of Bozi, RDTs for HIV were already available. Patients might have been afraid to have their HIV status revealed, and hence explaining their reluctance to undergo an RDT for malaria. Reports from Tanzania showed that people had the same feeling of fear towards RDTs. Nevertheless the usage of RDTs was of little matter when they understood that this test confirmed malaria presence and helped to make effective and right prescription for the most appropriate drugs leading to cure
. Our findings thus emphasize the importance of information, education and communication (IEC) readily adapted to the local context.
Some social parameters had no influence on RDTs acceptance, but played a more subtle role. We noted that higher education level was a factor of better adherence to RDTs. In these rural areas those who were educated seek information from the specialized people as indicated. Thus, they received appropriate responses to their concerns and questions. Attitudes and behaviour towards RDTs was also partly motivated by the strict observance of religious prohibitions. These aspects prevented proper social integration of malaria RDTs to these rural communities.
In other areas, RDTs for malaria were well accepted by volunteers from the community. This was the most appropriate way to diagnose asymptomatic cases of malaria
. Urban populations were more ready and able to purchase malaria RDTs, while rural population and the poorest of the poor preferred RDTs free of charge
. In some countries, health workers use RDTs but adherence to the result is low
[48–50]. For example, low adherence to RDTs was observed in rural parts of Burkina Faso because the health workers were more confident to the usual malaria symptoms from their experience than any new malaria test, which sometimes challenged their classical diagnosis
 or it could be related to their inability to better perform and interpret results from the test
Our study has some limitations. First, we pursued a convenience sampling and the size of our sample is relatively small (i.e. 100 RDTs for malaria were provided free of charge to a single health centre and a total of 100 people were interviewed). Second, within two months 100 individuals seeking care at the Bozi health centre met our inclusion criteria (i.e. axillary temperature >37.5°C), and hence were offered an RDT for malaria, but only about a third were willing to perform the rapid test. Due to time and budget constraints, we were unable to run the study until all 100 RDTs had been utilized. Third, our cross-sectional questionnaire survey was carried out two months after the introduction of RDTs for malaria, which might have introduced some recall bias. Finally, based on a single health centre and some observations that patients were no entirely satisfied with the overall quality of the service, it is difficult to generalize our findings. Clearly, our study was designed as an exploratory piece, and hence larger-scale studies should be undertaken to assess the full validity of the findings reported here.