Background <p>While the expanded use of malaria rapid diagnostic tests (RDTs) in Sub-Saharan Africa has improved testing rates, healthcare workers do not always adhere to results or report them accurately. Because misrecording RDT results compromises malaria surveillance, this study identified factors associated with providers’ guideline adherence and accurate RDT reporting in in two high-burden regions in Côte d’Ivoire.</p> Methods <p>This qualitative study was embedded within a mixed-methods evaluation of RDT reporting and recording accuracy called the Malaria RDT Capture and Reporting Assessment (MaCRA). Healthcare workers performed RDTs for patients with suspected malaria and recorded interpretations in registers. RDTs were photographed and independently read by an external panel; agreement was measured using Cohen’s kappa. Sixteen healthcare workers (eight high agreement, eight low agreement) with ≥ 75 recorded results were purposively selected across regions and districts. Semi-structured interviews in French covered RDT knowledge, perceived self-efficacy for performing and interpreting RDTs, perceived risks, subjective norms, guidelines, and health system context. Blinded analysts coded transcripts in NVivo using deductive and inductive approaches to compare themes between groups.</p> Results <p>Perceptions of RDT reliability, particularly confidence in negative results for symptomatic patients, was the primary differentiator between groups. Low-agreement participants more frequently feared false-negative results and severe consequences of failing to provide antimalarials, contributing to prescribing antimalarials after a negative RDT. Several described deliberate misrecording to align registers with treatment decisions, including changing negative results to positive or omitting antimalarial documentation to avoid scrutiny. Conversely, some high-agreement participants documented these cases as “presumed” malaria rather than falsifying results.</p> Conclusions <p>Differences in guideline adherence and RDT recording were driven by risk perceptions and confidence in results rather than a lack of procedural knowledge, guideline access, or supply constraints. Interventions should target clinical decision-making for RDT-negative fevers through supportive supervision, expand non-malarial diagnostic options, and strengthen documentation systems to record non-adherence transparently and without incentivizing misreporting.</p>