Overcoming Cognitive and Contextual Challenges in Febrile Illness Diagnosis: Design Implications for Clinical Decision Support Systems in Sub-Saharan Africa

Febrile illness contributes significantly to mortality and socioeconomic burden in Sub-Saharan Africa. Clinical decision-making is complex due to overlapping symptoms, limited lab infrastructure, resource constraints, and the cognitive demands placed on healthcare professionals. Despite growing deployment of clinical decision support systems (CDSS) and point-of-care diagnostics, adoption and sustained use remain limited, as many tools prioritize tests or guideline enforcement while overlooking diagnostic reasoning and contextual realities. We report findings from semi-structured interviews with 26 healthcare professionals in Ghana examining cognitive and contextual challenges in febrile illness diagnosis. Using reflexive thematic analysis, we identify interacting cognitive challenges (e.g., reasoning under uncertainty, heuristic decision-making, premature closure) and contextual constraints (test availability, patient costs, communication barriers, fragmented documentation) that shape diagnostic trajectories. We show how these challenges accumulate across diagnostic stages and reinforce empirical treatment. We outline implications for designing workflow-aligned CDSS that support diagnostic reasoning under real-world constraints in low-resource settings.