Malaria treatment-seeking behaviour and its associated factors: A cross-sectional study in rural East Nusa Tenggara Province, Indonesia

Health Education Campaign to Improve Malaria Knowledge, Prevention, and Treatment Behaviors in Rural East Nusa Tenggara Province, Indonesia: Protocol for a Cluster-Assigned Quasi-Experimental Study

BACKGROUND

Malaria is a major health issue that is distributed across 85 countries globally including Indonesia. Indonesia is in the process of achieving malaria elimination. Currently, a high burden of malaria exists in the rural eastern part of the nation, including East Nusa Tenggara Province where the number of malaria cases increased significantly during COVID-19. To achieve malaria elimination, malaria awareness must be measurable and integrated into malaria policy. Currently, malaria awareness among rural communities in the region is low, and interventional studies aiming at improving malaria awareness in rural areas in Indonesia are poorly documented.

OBJECTIVE

This study aims to investigate the impact of a local wisdom-based health education campaign combining local music, the voice of subdistrict leaders, and loudspeaker announcements on malaria-related behaviors in rural communities. Specifically, we aim to assess the effect of this intervention on (1) improvement in the malaria awareness index among rural communities and their associated factors, (2) changes in appropriate malaria treatment-seeking behavior (AMTSB) and its associated factors, (3) enhancements in knowledge and practice of malaria prevention measures and their associated factors, and (4) increased use of long-lasting insecticide-treated nets and their associated factors.

METHODS

This study used a cluster-assigned quasi-experimental design with pretest and posttest assessments in control and intervention groups. The control group, consisting of 12 villages, received malaria education integrated into routine health services provided by local health centers. The intervention group, comprising 13 villages, received the same education as the control group, in addition to a malaria campaign conducted once a week for 20 weeks. Before and after the campaign, a household survey was conducted to assess behavioral aspects of malaria, including general knowledge of malaria, AMTSB, and malaria prevention measures knowledge and practice. Improvement in the malaria awareness index, AMTSB, good level of malaria prevention measure knowledge, and good level of malaria prevention measure practice will be determined based on the difference scores for each index before and after the intervention in both groups. The chi-square test will be used to assess score differences. Binary logistic regression analysis will be conducted to identify key risk factors associated with changes in each index.

RESULTS

The intervention was conducted from the last week of August 2024 to the second week of January 2025. A total of 894 respondents participated before and after the intervention. The project is currently in progress, with multiple papers being drafted for publication in peer-reviewed journals.

CONCLUSIONS

This study is expected to provide significant findings to comprehensively investigate the change in behavioral aspects of malaria due to a local wisdom-based malaria education campaign. The findings could assist stakeholders in Indonesia with developing malaria health policies that are contextually relevant, thereby supporting global efforts to achieve malaria-free status by 2030.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66982.

Towards promoting timely treatment: Uncovering the determinants of prompt malaria care seeking behavior among febrile children under-five years in Tanzania

BACKGROUND

Prompt diagnosis and effective treatment within 24 hours of fever onset is crucial for reducing malaria-related morbidity and mortality in under five children. However, research on the prompt care-seeking behaviors and their determinants in this demographic is limited. This study examined the prevalence of prompt care-seeking behaviors among under five febrile children in Tanzania and the associated determinants.

METHODS

This cross-sectional study analyzed data from the 2022 Tanzania Demographic and Health Survey (TDHS), including a nationally representative and weighted sample of 1,050 under-five children who experienced fever within two weeks prior to the survey. A weighted univariable and multivariable modified Poisson regression model with robust estimator was used to examine the association between prompt care seeking behaviors and explanatory variables, including child and caregivers' factors.

RESULTS

The prevalence of prompt care seeking for febrile children was 43.2%. Caregivers of female children had 18% less prevalences of seeking prompt care (95% CI 0.68-0.98) compared to caregivers with their male children. Caregivers aged 25-34 and 35-49 years had 36% (95% CI 1.05-1.78) and 61% (95% CI 1.16-2.23) higher prevalences of seeking prompt care for their children respectively, compared to younger caregivers aged 15-24 years. Caregivers with at least primary education had 50% (95% CI 1.12-2.02) higher prevalences of seeking prompt care compared to those with no formal education. Additionally, an increase in one household member was associated with a 3% increase in the prevalence of seeking prompt malaria care (95% CI 1.01-1.05).

CONCLUSION

In Tanzania, female children under five experience delays in care-seeking for malaria, whereas older and more educated caregivers are more likely to seek timely treatment for their children. To enhance health outcomes in this vulnerable group, targeted interventions should prioritize raising awareness among caregivers, particularly younger ones and prompting equitable care seeking to all children regardless of sex.

Delays in seeking healthcare and its determinants among malaria patients in Ethiopia: A systematic review and meta-analysis

METHODS

PubMed, Cochrane Library, Scopus, Web of Science, Google Scholar and Google were searched. Cross-sectional and case-control studies about delays in seeking healthcare for more than 24 hours were included. STATA 17 was used to analyze the data. Heterogeneity across studies was assessed via the I2 test. A funnel plot and Egger's test were used to assess publication bias. Subgroup analyses were performed by region and study setting. Sensitivity analysis was performed to determine the influence of individual studies.

RESULTS

A total of 18 articles with 7371 participants were included in this review. The pooled prevalence of delay in seeking healthcare was 67% (95% CI: 51%-84%). Age less than 15 years (OR: 2.27, 95% CI: 1.34-3.85), inability to read and write (OR: 3.36, 95% CI: 1.18-9.69), travel to health institutions on foot (OR: 2.77, 95% CI: 1.71-4.49), and by horse (OR: 2.76, 95% CI: 1.57-4.84), living far from a health institution (OR: 2.65, CI: 1.37-5.13), not having a family history of death (OR: 3.04, 95% CI: 2.14-4.33), and not being a member of community-based health insurance (OR: 7.14, 95% CI: 1.09-46.63) were significant determinants of delays in seeking healthcare.

CONCLUSION

The pooled prevalence of delays in seeking healthcare was high, and most of the determinants were modifiable. These findings underscore the need for targeted interventions to address these barriers and improve timely access to healthcare for affected populations.

The proportion and determinants of appropriate health seeking behavior for febrile illness among caregivers of children under-five years in Butula sub-county, Busia county, Kenya

Background

Almost 10 million children under the age of five in Kenya, die due to fever-related diseases. In Busia, a county in Kenya, malaria accounts for 13% of all child fatalities under the age of five, a number higher than any other county. This study aimed to determine (a) proportion of appropriate health-seeking behavior and (b) determinants of health-seeking behaviors (HSBs) among their caregivers in Butula Sub-County, Busia County, as reported by the caregivers.

Methods

This cross-sectional mixed-method study included 271 caregivers, 11 community health volunteers, and health facility workers in Butula Sub-County. Systematic random sampling for participants and purposive sampling for key informants were used. A questionnaire collected the data that was analysed using frequency and percentages and logistic regression.

Results

Around seventy percent of caregivers reported seeking care for a child's fever within 24 hours. Individual factors that caregivers reported to influence appropriate health-seeking HSB were unemployment (adjusted odds ratio (aOR) = 0.49, 95% CI: 0.217 - 0.593, p = 0.018), self-medication preference (aOR = 0.14, 95% CI: 0.054 - 0.363, p < 0.001), had atleast two children (aOR = 0.63, 95% CI: 0.425 - 0.937, p = 0.042), and confidence in identifying fever (aOR = 7.0, 95% CI: 2.200 - 22.439, p = 0.001). Health-system factors reported to influence HSBs were facility too far (aOR = 0.86, 95% CI: 0.526 - 0.914, p = 0.027), getting health education (aOR = 1.8, 95% CI: 1.201-4.122, p=0.015), and facility level (aOR = 4.4, 95% CI: 2.015 - 9.750, p < 0.001). Qualitative findings found health system factors related to HSB as stockouts, facility distance, and staff workload.

Conclusions

Employment, multiple children, preferences to self-medicate, confidence in fever identification, facility level, distance to facility, and education are ky factors affecting caregiver's HSB. Policy and practice efforts should focus on these significant individual and health system determinants for HSBs among caregivers of children under five with febrile illness.

Magnitude and associated factors of delayed treatment seeking among patients with malaria in Andabet district, Northwest Ethiopia, 2022: a multicentre institution-based cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence of delayed treatment seeking and its associated factors among patients with malaria in the Andabet district, Northwest Ethiopia, 2022.

DESIGN

An institution-based cross-sectional study was conducted from 8 July 2022 to 21 August 2022. Data were collected from malaria patients using structured and pretested questionnaires and entered using Epi data V.4.6 and analysed by using Stata SE V.14. Both bivariable and multivariable logistic regression analyses were used to identify the factors associated with delay seeking treatment among malaria patients. P values less than 0.05 with 95% CI and adjusted OR (AOR) were considered statistically significant.

SETTING

The study was conducted in the Andabet district, Northwest Ethiopia.

PARTICIPANTS

A total of 403 malaria patients participated in this study. The sample was allocated proportionally for the six health centres and participants were selected through systematic random sampling techniques.

OUTCOME MEASURES

The primary outcome is the prevalence of delay in seeking malaria treatment.

RESULTS

A total of 403 malaria patients with a mean age of 27.6±SD 14.26 years were included in this study. The prevalence of delayed malaria treatment seeking was 78.41% (95% CI 74.11%, 82.17%). Do not know the cause of malaria (AOR=2.24, 95% CI (1.07, 4.65)), do not know malaria signs and symptoms (AOR=2.52, 95% CI (1.04, 6.07)), distance greater than 5 km travelled (AOR=5.37, 95% CI (1.22, 23.55)) and fear of treatment cost (AOR=1.88, 95% CI (1.05, 3.36)) were the statistically significant factors associated with delayed treatment seeking among malaria patients.

CONCLUSIONS

The prevalence of delayed malaria treatment was high. Lack of knowledge of the cause of malaria, lack of knowledge of malaria signs and symptoms, a distance greater than 5 km travelled and fear of treatment cost were significantly associated with delayed malaria treatment seeking. Therefore, community awareness of early treatment is crucial.

Toward Malaria Elimination: Understanding Awareness, Prevention, and Health-Seeking Patterns in Odisha, India

Given India's goal of eliminating malaria by 2030, this study aimed to investigate community perspectives on malaria in highly endemic areas of Odisha, a region historically prone to malaria. The research explores self-reported malaria events, community knowledge, attitudes, practices, health-seeking behaviors, and access to healthcare services. A community-based cross-sectional survey conducted among 387 households between November 2022 and May 2023 served as an extension of our recent project, monitoring malaria elimination efforts in remote and challenging-to-reach communities in Odisha. The participants, who had a mean (SD) age of 41.7 (13.17) years, were predominantly male (88.4%). Self-reported malaria in the last 12 months prior to the survey was 6.2%, with half of the patients opting for primary health centers for treatment, averaging a 5-day recovery per episode. The median cost per malaria treatment episode was U.S. dollars 20.17. A significant majority (79.8%) demonstrated a strong awareness of malaria symptoms and transmission, with 83.3% expressing a favorable attitude toward disease prevention. Notably, 65.1% reported consistent use of long-lasting insecticidal nets. However, nearly half of the participants reported inadequate larval source management and indoor residual spraying services. Although there were slight variations in knowledge, attitude, and practice scores among demographic groups, the overall understanding of and approach to malaria were consistent in the study population, with no statistically significant differences (P >0.05). The study findings offer hope, suggesting that with sustained dedication and focused surveillance, malaria could become a thing of the past.

Treatment-seeking behavior for malaria among communities in Indonesia: A systematic review

Indonesia stands as one of the nine malaria-endemic countries in Southeast Asia with a total of 443,530 cases in 2022. Eastern Indonesia is listed as an area with high malaria endemicity and the Indonesian government has set a target of eliminating malaria by 2030. From 2010 to 2014, the number of malaria cases decreased but stagnated until 2020 and have continued to increase. Stagnation may occur as a result of many non-medical treatment-seeking behaviors. The aim of this systematic review was to provide a summary and overview of malaria treatment-seeking behavior among communities in several regions in Indonesia. The searches were conducted through four databases (Cochrane, PubMed, Google Scholar, and ScienceDirect) using medical subject headings (MeSH) "treatment-seeking behavior" OR "health-seeking behavior" AND "malaria" AND "Indonesia". This systematic review was limited to studies conducted in Indonesia that were published between 2013 and 2023 using either a quantitative or qualitative approach. Out of 2831 studies, a total of thirteen studies were included. The pattern of seeking malaria treatment varied between doing nothing or no action, self-treatment (purchasing drugs at pharmacies and consuming leftover medicines), traditional medicine, and medical treatment (public health facilities or malaria control clinics). Those behaviors are attributed to education level, socioeconomic level, occupation, distance from home to health facilities, geographical conditions, and people's perceptions of malaria and antimalarial medicines. There is still a range of malaria treatment-seeking behavior outside of recommended medical treatment in communities in several regions in Indonesia. The phenomenon of medical pluralism and syncretism requires approaches from various sectors in order to achieve a malaria-free Indonesia by 2030.

Treatment-seeking behaviours of malaria patients versus non-malaria febrile patients along China-Myanmar border

BACKGROUND

Appropriate malaria treatment-seeking behaviour (TSB) is critical for timely detecting malaria, prompt treatment, and prevention of onward transmission of the disease in a community. This study aimed to compare treatment-seeking behaviours between malaria patients and non-malaria febrile patients, and to analyse the factors associated with appropriate TSB along the China-Myanmar border.

METHODS

A cross-sectional study was carried out to investigate the appropriate TSB of microscopy-confirmed malaria patients versus non-malaria febrile (NMF) patients. An unconditional logistic regression analysis (LRA) was used to identify factors associated with appropriate TSB.

RESULTS

Among 223 malaria patients and 446 NMF patients, 129 (57.8%) of the malaria patients versus 163 (36.5%) of the NMF patients firstly sought treatment in health facilities without laboratory testing for malaria (P < 0.0001). A total of 85(38.1%) of the malaria patients versus 278 (62.3%) of the NMF patients had appropriate TSB, namely, seeking treatment in health facilities with laboratory testing for malaria within 48 h (P < 0.0001). Multivariate LRA identified that the malaria patients with Chinese nationality had less appropriate TSB compared to those with other nationalities (adjusted odds ratio [AOR]: 0.21, 95% confidence interval CI 0.07-0.68, P = 0.0097), and malaria patients residing in urban areas had more appropriate TSB compared to those living in rural areas (AOR: 2.16, 95%CI 1.06-4.39, P = 0.0337).

CONCLUSIONS

TSB was not appropriate in malaria patients. Chinese citizenship and rural residence were two independent factors associated with inappropriate malaria TSB. It is urgently necessary to improve appropriate malaria TSB through effective campaigns of information, education, and communication for malaria control in Myanmar and preventing reestablishment of malaria transmission in Yunnan, China.

Assessing caregivers' perceptions of treatment-seeking for suspected severe malaria in the Democratic Republic of the Congo

BACKGROUND

Malaria remains a major public health issue in the Democratic Republic of the Congo (DRC), accounting for 44% deaths among outpatient visits in children < 5 years of age, and 22% of facility deaths. Understanding determinants of caregivers' treatment-seeking patterns and decision-making is crucial in reducing the malaria burden.

METHODS

In the frame of the Community Access to Rectal Artesunate for Malaria (CARAMAL) project, cross-sectional household surveys that randomly sampled villages and households were carried-out in three rural DRC health zones prior to the rollout of pre-referral Rectal Artesunate (RAS) and then 9 and 19 months after RAS rollout (post-RAS). Data were captured electronically through face-to-face interviews with the main caregivers of children < 5 years. Capillary blood samples of the children were tested for malaria and anaemia. The main study outcome was whether caregiver "sought treatment outside home" when the child had fever. Multilevel mixed effects logistic regression models using village as random effect and health zone as a fixed effect was performed to assess treatment-seeking predictors.

RESULTS

2439 household interviews were completed (pre-RAS 888 and post-RAS 1551), including 316 and 653 treatment-seeking interviews. Overall, 3499 children < 5 years were tested for malaria and anaemia (pre-RAS 1,315 and post-RAS 2184). Caregiver's recognition of severe malaria signs was poor, while knowledge of symptoms of uncomplicated malaria seemed high. Despite this, danger signs significantly increased the odds of seeking treatment (aOR = 2.12, 95%CI 1.03-4.38), the same was found for the "least poor" quintile (aOR = 3.01, 95%CI 1.03-8.82), as well as residents of Kingandu (aOR = 2.78, 95%CI 1.01-7.65). "Doing something at home" against fever negatively affected treatment-seeking in both study phases. RAS acceptance was high, at almost 100%. Malaria prevalence was higher post-RAS (45.2%) compared to pre-RAS (34.4%), p = 0.003, but anaemia, although high (≥ 75%), was similar in both study phases (p = 0.92).

CONCLUSION

In remote communities with high malaria prevalence in the DRC, malaria remains a major problem. Improving the recognition of danger signs of severe disease and introducing pre-referral RAS may improve treatment-seeking and contribute to reducing malaria-related mortality among children-if quality of care can be guaranteed.

Effect of malaria prevention education on bed net utilization, incidence of malaria and treatment seeking among school-aged children in Southern Ethiopia; cluster randomized controlled trial

BACKGROUND

School-aged children (SAC) have an increased risk to contract malaria and play a major role in its transmission dynamics. However, their malaria prevention experience is poor. Thus, the effect of malaria prevention education (MPE) on bed net utilization, treatment seeking from a health facility and cumulative incidence of malaria was evaluated in Southern Ethiopia.

METHODS

A two arm cluster randomized controlled trial was conducted by recruiting 2038 SAC from 32 schools. Structured questionnaire was used to collect data on socio-demographic, economic, bed net ownership, bed net utilization, whether the participated child suffered from malaria and has got treatment from a health facility. Generalized mixed effect logistic regression using school as random variable was used to assess the effect of the intervention on the outcome variables.

RESULTS

The ownership of bed net in households of the control and intervention schools was similar respectively with 84.6 and 88.6% (Crude Odds Ratio (COR): 1.5; 95%CI: 0.5-4.8). The percentage of SAC slept under the bed net the night before the survey was also similar (55.1% versus 54.0%); COR:1.04; 95%CI: 0.5-2.4). Bed net utilization was affected by household size to the bed net ratio ≤ 2 (Adjusted Odds Ratio (AOR) = 1.6; 95%CI:1.3-2.1), bed net utilization at baseline of the study (AOR = 2.3; 95%CI:1.5-3.6), and history of malaria attack in the last twelve months (AOR = 1.3; 95%CI:1.01-1.8). Reported cumulative incidence of malaria and treatment seeking from a health facility by SAC was similar between intervention and control arms: -2.1% (COR = 0.8; 95%CI: 0.5-1.5) and 9.6% (COR = 1.4; 95%CI: 0.4-4.3) respectively. The reported incidence of malaria was affected by altitude (AOR = 0.5; 95%CI: 0.3-0.8), low and medium wealth index (AOR = 0.7; 95%CI: 0.5-0.96 and AOR = 0.7; 95%CI: 0.5-0.98), adequate bed net number for household members (AOR = 0.7; 95%CI:0.5-0.9) and bed net utilization (AOR = 1.3; 95%CI:1.1-1.8).

CONCLUSIONS

MPE had no significant effect on the use of malaria prevention measures considered, treatment seeking from a health facility and reported cumulative incidence of malaria though bed net use was associated with malaria incidence. Before organizing any health education program, sustainable implementation efforts have to be warranted especially in SAC, a neglected but relevant vulnerable and reservoirs.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR202001837195738, registered 21/01/2020.

Malaria diagnosis in rural healthcare facilities and treatment-seeking behavior in malaria endemic settings in western Kenya

Accurate malaria diagnosis and timely treatment are requirements for effective management of the disease. However, treatment efficacy may be significantly reduced in resource-constrained healthcare facilities with poorly equipped laboratories and frequent drug and rapid diagnostic test kit (RDT) stock-outs. Furthermore, patient may avoid seeking treatment from such facilities. The study's goal was to determine treatment-seeking behavior, malaria diagnosis and treatment quality, and likely treatment-seeking determinants in the local population. Passive case detection, which targeted all patients with suspected malaria cases, was conducted in ten public healthcare facilities over a three-month period. Monthly malaria cases, methods of diagnosis and antimalarial drug availability were assessed. A household-based survey was also carried out. Structured questionnaires were used to collect knowledge, attitude and practice (KAP) data from household heads. Malaria knowledge, treatment seeking behavior, and predictors of malaria treatment-seeking were all determined. Three of the seven dispensaries lacked a laboratory to conduct microscopy- diagnosis. These three dispensaries also experienced frequent RDT stock-outs, which resulted in depending on clinical signs as diagnosis for malaria. The majority of local residents with fever (50.3%) purchased antimalarial drugs from a chemist. About 37% of fever patients sought treatment at healthcare facility while the remaining 12.7% did not treat their fevers. In irrigated areas, 45.5% (46/64) of fever patients sought treatment at healthcare facilities, compared to 25% (18/64) in non-irrigated areas (p = 0.009). Most children aged below 5 who had fever (77.7%) were taken to healthcare facility for treatment compared to 31.4% of children aged 5-14 years or 20.9% of adults (0.0001). Predictors of treatment seeking included access to healthcare facility (OR = 16.23, 95% CI: 2.74-96.12), and ability to pay hospital bills (OR = 10.6, 95% CI: 1.97-57). Other factors that influenced health-seeking behavior included the severity of symptoms, the age of the patient and knowledge of malaria symptoms.