Factors Associated with Malaria Care-Seeking for Among Children Under 5 Years of Age in Mozambique: A Secondary Analysis of the 2018 Malaria Indicator Survey

BackgroundMozambique is ranked fourth in a list of the 29 countries that accounted for 95% of all malaria cases globally in 2019. The aim of this study was to identify factors associated with care-seeking for fever, to determine the association between knowledge about malaria and care-seeking and to describe the main reasons for not seeking care among children under five years of age in Mozambique.MethodsThis is a quantitative, observational study based on a secondary data analysis of the 2018 Malaria Indicatory Survey. This weighted analysis was based on data reported by surveyed mothers or caregivers of children aged 0-59 months who had fever in the two weeks prior to the survey.ResultsCare was reportedly sought for 69.1% [95% CI 63.5-74.2] of children aged 0-59 months old with fever. Care-seeking was significantly higher among younger children, <6 months old (AOR=2.47 [95% CI 1.14-5.31]), 6-11 months old (AOR=1.75 [95% CI 1.01-3.04]) and 12-23 months old (AOR=1.85 [95% CI 1.19-2.89]), as compared with older children (48-59 months old).In adjusted analysis, mothers from the middle (AOR=1.66 [95% CI 0.18-3.37]) and richest (AOR=3.46 [95% CI 1.26-9.49]) wealth quintiles were more likely to report having sought care for their febrile children than mothers from the poorest wealth quintile. Additionally, mothers with secondary or higher education level were more likely to seek care (AOR=2.16 [95% CI 1.19-3.93]) than mothers with no education. There was no association between maternal malaria knowledge or reported exposure to malaria messages and care-seeking behaviors.The main reasons reported for not seeking care included distance to health facility (46.3% of respondents), perception that the fever was not severe (22.4%) and the perception that treatment was not available at the health facility (15%).ConclusionHealth facility access and socioeconomic barriers continue to be important constraints on malaria service utilization in Mozambique.

The moderated mediation role of malaria knowledge and household income in the relationship between insecticidetreated mosquito nets and malaria prevalence

Objectives: The study was premised on the notion that insecticidetreated mosquito nets are positively related to malaria prevalence, and that knowledge mediates the relationship between insecticide-treated mosquito nets and malaria. Furthermore, household income was hypothesized to have a moderating effect on the direct and indirect relationships (through malaria knowledge) between insecticide-treated mosquito nets and the prevalence of malaria. Methods: The hypothesized relationships were examined using panel data collected from ten regions of Ethiopia during 2011 – 2015. Structural equation modeling and the random effect model were used to test the hypotheses. Statistical analyses were performed using Stata version 13.0. Results: The results were consistent with our proposed hypotheses, showing a significant relationship between the research variables. The findings suggest that malaria knowledge contributes to improving the relationship between insecticide-treated mosquito nets and malaria prevalence. A positively significant indirect effect (β = 0.47, p = 0.003) as well as direct effect (β = 0.28, p = 0.001) was revealed in the study. Furthermore, a positive impact of household income in strengthening the relationship between insecticide-treated mosquito nets and malaria through knowledge reported, with a considerable value (β = 0.13, p = 0.000). The result also reveals differences in the outcome of malaria prevalence at different levels of household income category, where the indirect effect of insecticide-treated mosquito nets on malaria prevalence via malaria knowledge was positive and significant for households under the second-level income category (β = 0.15, p = 0.000). Conversely, the indirect effect of insecticide-treated mosquito nets on malaria prevalence via malaria knowledge was negative for the high level-income category (β = -0.14, p = 0.022). Besides, insignificant and negative relationships were reported for households under low-level income categories (β = 0.024, p = 0.539). Conclusion: The findings are potentially useful for the health sector to ensure success in infectious disease prevention and control, particularly malaria, and to explain how various factors contribute to the relationship. Keywords: malaria; insecticide-treated mosquito nets; malaria knowledge; household-income; structural equation modelling.

The Moderated Mediation Role of Malaria Knowledge and Household Income in the Relationship between Insecticide-Treated Mosquito Nets and Malaria

Objectives: The study was premised on the notion that insecticide-treated mosquito nets are positively related to malaria prevalence, and that knowledge mediates the relationship between insecticide-treated mosquito nets and malaria. Furthermore, household income was hypothesized to have a moderating effect on the direct and indirect relationships (through malaria knowledge) between insecticide-treated mosquito nets and the prevalence of malaria. Methods: The hypothesized relationships were examined using panel data collected from ten regions of Ethiopia during 2011-2015. Structural equation modeling and the random effect model were used to test the hypotheses. Statistical analyses were performed using Stata version 13.0. Results: The results were consistent with our proposed hypotheses, showing a significant relationship between the research variables. The findings suggest that malaria knowledge contributes to improving the relationship between insecticide-treated mosquito nets and malaria prevalence. A positively significant indirect effect (β = 0.47, p = 0.003) as well as direct effect (β = 0.28, p = 0.001) was revealed in the study. Furthermore, a positive impact of household income in strengthening the relationship between insecticide-treated mosquito nets and malaria through knowledge was reported, with a considerable value (β = 0.13, p = 0.000). The result also reveals differences in the outcome of malaria prevalence at different levels of household income category, where the indirect effect of insecticide-treated mosquito nets on malaria prevalence via malaria knowledge was positive and significant for households under the second-level income category (β = 0.15, p = 0.000). Conversely, the indirect effect of insecticide-treated mosquito nets on malaria prevalence via malaria knowledge was negative for the high level-income category (β = -0.14, p = 0.022). Besides, insignificant and negative relationships were reported for households under low-level income categories (β = 0.024, p = 0.539). Conclusion: The findings are potentially useful for the health sector to ensure success in infectious disease prevention and control, particularly malaria, and to explain how various factors contribute to the relationship.

Malaria Care-Seeking and Treatment Ideation among Gold Miners in Guyana

Background Although miners are a priority population in malaria elimination in Guyana, scant literature exists on the drivers of malaria-related behaviour. This study explores the relationship between gold miners’ malaria-related ideation and the adoption of malaria care-seeking and treatment behaviours including prompt care-seeking, malaria testing, and self-medication. Methods Data are from a cross-sectional quantitative survey of 1685 adult miners between the ages of 18–59 years who live in mining camps in Regions 1, 7, and 8. The analysis focused on miners who reported an episode of fever in the past year (n = 745). Malaria care-seeking and treatment ideation was defined as a composite additive score consisting of the following variables: general malaria knowledge, perceived severity, perceived susceptibility, beliefs, perceived self-efficacy, perceived norms, interpersonal communication, and perceived response efficacy. Multivariable logistic regressions explored the relationship between ideation on care-seeking/treatment behaviours, controlling for confounding variables. Results Most miners with a recent episode of fever had perceived risk (92%), self-efficacy (67%), susceptibility (53%) and high malaria knowledge (53%). Overall, miners' care-seeking/treatment ideation score ranged from 0 to 8 with a mean of 4.1. Ideation scores were associated with higher odds of care-seeking for fever (aOR:1.19; 95% CI: 1.04–1.36), getting tested for malaria (aOR: 1.22; 95% CI: 1.07–1.38) and lower odds of self-medication (aOR: 0.87; 95% CI: 0.77–0.99). Conclusions A national community case management initiative is using study findings as part of its scale-up, using volunteers to make testing and treatment services more accessible to miners. This is complemented by a multi-channel mass media campaign to improve miners’ ideation. Communication messages focus on increasing miners’ knowledge of malaria transmission and symptoms, encourage positive beliefs about malaria testing and volunteer testers, promote evidence about the effectiveness of testing, and reminders of how quick and easy it is to get a malaria test with the community case management initiative. Study findings also have implications for efforts to eliminate malaria across the Guiana Shield.

A Malaria Knowledge, Attitudes and Practice Survey in a Rural Community in Guinea.

Malaria is the top public health problem in the Republic of Guinea. In 2016, we conducted a cross-sectional household survey in Timbi-Touni, Guinea using community workers. The survey included respondent demographic characteristics, child health, child health promotion related to malaria knowledge, water and sanitation, and health services access. Majority of our respondents were women (89.41%) and had never been to school (71.18%). Slightly more than half the children were reported to have ever had malaria and 45% reported to have ever had diarrhea. We did not find any statistically significant association between gender or level of education and malaria knowledge. Eighty six percent of respondents had received a free bednet during national campaigns and 61% slept under a bednet the night before the survey. We found a statistically significant association between receiving information on malaria prevention and sleeping under a bednet. There was no statistically significant association between drinking water source and malaria or diarrhea. Both malaria and diarrhea were considered to be serious illnesses for adults and children by nearly all respondents. Insights from our detailed KAP survey can guide policy makers and practitioners who design and implement malaria control and prevention measures in Guinea.

Malaria prevention and care seeking among gold miners in Guyana

Despite being a priority population in malaria elimination, there is scant literature on malaria-related behavior among gold miners. This study explores the prevalence and factors influencing malaria prevention, care seeking and treatment behaviors in Guyana gold mining camps. A cross sectional survey was conducted among adult gold miners living in mining camps in the hinterland Regions 1 (Barima-Waini), 7 (Cuyuni-Mazaruni), and 8 (Potaro-Siparuni). Multivariable logistic regressions explored factors associated with miners’ self-report of mosquito net use, prompt care-seeking; self-medication; and testing for malaria. A third of miners used a mosquito net the night preceding the survey and net use was higher among those who believed that net use was the norm in their camp (aOR: 3.11; 95% CI:1.65, 5.88). Less than half (45%) of miners had a fever in the past 12 months, among whom 36% sought care promptly, 48% tested positive for malaria while 54% self-medicated before seeking care. Prompt care-seeking was higher among miners with high malaria knowledge (aOR: 1.44; 95% CI: 1.01, 2.05). Similarly, testing rates increased with secondary education (aOR: 1.71; 95% CI: (1.16, 2.51), high malaria knowledge (aOR: 1.45; 95% CI: 1.02, 2.05), positive beliefs regarding malaria transmission, threat, self-diagnosis, testing and treatment, and, trust in government services (aOR: 1.59; 95% CI (1.12, 2.27) and experience of a prior malaria episode (aOR: 2.62; 95% CI: 1.71, 4.00). Self-medication was lower among male miners (aOR: 0. 52; 95% CI: 0.32, 0.86). Malaria prevention and care seeking behaviors among miners are somewhat low and influenced by mosquito net usage, perceived norms, malaria knowledge and prior episode of confirmed malaria. Study findings have implications for malaria interventions in the hinterland regions of Guyana such as the mass and continuous distribution of insecticide treated nets as well as community case management initiatives using trained malaria testing and treatment volunteers to curb malaria transmission among remote gold mining populations. These include efforts to identify and address gaps in distributing mosquito nets to miners and address miners’ barriers to prompt care seeking, malaria testing and treatment adherence. Targeted social and behavior change messaging is needed on net acquisition, use and care, prompt care-seeking, malaria testing and treatment adherence. Additional efforts to ensure the overall sustainability of the community case management initiative include increased publicity of the community case management initiative among miners, use of incentives to promote retention rates among the community case management volunteer testers and public private partnerships between the Guyana Ministry of Health and relevant mining organizations.

The Knowledge, Attitudes and Practices of Malaria and The Risk of Malaria Infection Among Chinese Population in Sierra Leone

Background: The risk of malaria importation from malaria hyperendemic regions has threatened the achievement of the malaria elimination goal of China. However, few studies have focused on malaria control interventions among Chinese population in Africa. The aims of this study were to assess the knowledge, attitudes and practices (KAP) of malaria and the risk of malaria infection among Chinese population in Sierra Leone, then to improve the knowledge of malaria among Chinese population in Sierra Leone through health education interventions. Methods: Cluster random sampling method was undertaken to select the overseas Chinese from 27 Chinese institutions as respondents in Sierra Leone. Cross-sectional surveys of malaria KAP and the risk of malaria infection were performed on respondents by trained investigators. Health education training were conducted to educate respondents knowledge of malaria after the surveys. The same questionnaires of malaria KAP as before the training were used to evaluate the effect of health education interventions. Correlation analyses of results were performed by T test, ANOVA, Chi-Square and Logistics regression model.Results: A total of 134 respondents fully completed questionnaires were analyzed before health education training with mainly engaged in (73.88%) outdoor work. Majority of participators (82.84%) were from 20 Chinese provinces. About half of participators (49.25%) had not received malaria health education before going abroad. The practices of prevention malaria were used in most respondents, 84.33% (113/134) used mosquito net every day, 90.30% (121/134) were equipped with screen doors and Windows in their dwellings, 73.88% (99/134) used mosquito repellent when going out, and 74.63% (100/134) used mosquito insecticide at home. The average awareness rate of malaria knowledge of respondents without malaria training before going abroad (41.69 %) was significantly lower than that of with malaria training (53.41%) (T =3.337, P=0.001).According to Logistics regression analysis, age (OR=2.6, 95%CI(1.0,8.8)) and male (OR=3.2, 95%CI(1.1,9.4)) were the main factors whether the awareness rate of malaria knowledge reaches 60% before the training. After health education training, the awareness rate of malaria knowledge of 134 respondents increased to 87.62 %, which was significantly higher than that of before the training (44.4%) (P < 0.05). 29.10% (39/134) of all respondents had infected malaria in the past year. 37.37% (37/99) of outdoor workers were infected with malaria, which was significantly higher than 5.71% (6/35) of indoor workers with a significant difference (χ2=12.561, P=0.000).According to Logistics regression analysis, outdoor work was the main risk factor for malaria infection (OR=6.5, 95%CI(1.3,31.7)).Conclusion The Chinese in Sierra Leone lacked malaria knowledge training with a low awareness of malaria knowledge, and had inadequate personal prevention with high risk of malaria infection. Health education training could improve their knowledge of malaria. That implies the publicity of malaria prevention and control and outdoor prevention and control measures for overseas Chinese in Sierra Leone should be strengthened.

Knowledge of risks of malaria in pregnancy on use of ITNs among pregnant women in northern Ghana

Background Every year malaria in pregnancy causes 10,000 maternal mortalities worldwide, 20% of stillbirths, 11% of all new-born deaths and 900,000 low-birth-weight babies in sub-Saharan Africa. Maternal knowledge of malaria risks in pregnancy plays a significant role in malaria prevention. However, it is unknown if this preventable loss of lives and morbidities are caused by lack of knowledge, lack of prevention tools or both. We measured the pregnancy-related risks of malaria knowledge and bed net availability and use among pregnant women in Ghana. Methods We interviewed 770 pregnant women who attended antenatal care in 37 primary care clinics in Ghana from January through May 2019. We integrated this data in a sequential explanatory design with qualitative insights from 6 focus groups with 8 pregnant women each. Results 697/770 questionnaires were analyzed. 67% have general knowledge on malaria prevention but only 19% knew the specific risks on pregnancy outcomes. ITNs were owned by 89%, but only 75% reported to regularly use them. There was a statistically significant correlation between specific risks of malaria knowledge and ITN use (P&lt;.001, OR = 2.0, CI:1.3-3.0). Other factors associated with ITN use were higher income, owning an ITN, higher parity, formal education, religion, and age. Reasons for non-adherence to ITN use include inappropriate hanging infrastructure, discomfort with using an ITN, and use of other prevention alternatives. Conclusions The study demonstrates that maternal knowledge on the risks of malaria in pregnancy significantly influenced their adherence to the use of insecticide-treated bed nets. Key messages The use of ITNs as a prevention method for malaria correlates to the knowledge of mothers about risks of malaria in pregnancy. Antenatal care malaria prevention efforts should focus more on teaching the specific risks of malaria in pregnancy.

Rural-urban disparities and factors associated with delayed care-seeking and testing for malaria before medication use by mothers of under-five children, Igabi LGA, Kaduna Nigeria

Background Fever in under-five children (U5) is the commonest presenting complaint in general practice and mothers’ recognition is an entry point for fever treatment, including malaria. This study describes rural-urban disparity in fever prevalence in U5, mothers’ malaria knowledge, care-seeking, testing for malaria before antimalaria medication and the associated factors.Methods A cross-sectional survey was conducted among 630 mother-child pairs (rural (300) and urban (330)) selected randomly using a multi-stage sampling from 63 villages in Igabi LGA, Kaduna State, Nigeria. Trained female data collectors administered a pre-tested structured questionnaire to collect information on mother-child demographic profiles, malaria knowledge, fever episodes in birth order last child in two weeks prior to survey, blood testing before antimalaria use, and delayed care seeking defined as care sought for fever >48 hours of onset. Malaria knowledge was categorized into good, average, and poor if the final scores were ≥75th, 50th-74th, and <50th percentiles, respectively. Frequency, proportions, and odds ratio were calculated. Statistically significant was set at p-value <0.05. Results The median age (interquartile range) of rural mothers was 30 (IQR, 10) years compared to 27 (IQR, 6) years in urban. Of the 70.0% (441/629) U5 children with fever, 58.5% (258/441) were in rural settlements. A third of the mothers whose child had fever sought care. Mothers in rural settlements were 2.8 (adjusted OR: 2.8, CI: 1.8-4.2, p <0.01) times more likely to delay care-seeking for fever. Other significant factors were poor or no knowledge of malaria transmission, poor perception of malaria as a major health problem, and household size > 5. Also, mothers who had no formal education were four times likely to receive antimalaria medications without testing fever for malaria compared to their educated counterpart (adjusted OR: 4.0, 95% CI: 1.6-9.9, p <0.000).Conclusions Rural-urban disparities existed between fever prevalence in U5 children, care-seeking practices by their mothers, and factors associated with delayed care-seeking and testing the fever for malaria before antimalaria medication. Fever treatment for high impact malaria elimination in Nigeria needs a context-specific intervention rather than ‘one-size-fits-all’ approach.