Psychosocial Factors Associated with Malaria Care-seeking in Rural Ethiopia

"Study findings can inform the design of evidence-based community engagement approaches that appropriately target caregivers in these regions and other similar settings."

Psychosocial factors, including social, cultural, and environmental phenomena, play a central role in health and behaviour change. Considering the critical role of prompt care-seeking in ensuring proper diagnosis and treatment of malaria, efforts have been made to understand the factors influencing care-seeking behaviours for children with fever, particularly at the caregiver level. This study explores the spectrum of prompt care-seeking behaviour and associated psychosocial factors among female caregivers of children under five years with fever in rural Ethiopia.

The ideation framework developed by Kincaid serves as the underpinning for this article:

Drawn from various behavioural theories, the framework recognises that most behavioural decisions are driven by psychosocial factors including cognitive, emotional, and social factors. Cognitive factors include knowledge of disease symptoms and of transmission and prevention, as well as attitudes, values, and attitudes related to proposed actions. Emotional factors include perceived severity and susceptibility to disease, perceived self-efficacy, and belief in the efficacy of proposed actions. Social factors include social support, social influence, spousal/partner communication, and personal advocacy.

The data presented in this article are drawn from survey data for the Communication for Health (C4H) project, a 5-year (2015–2020) project in Ethiopia funded by the United States Agency for International Development (USAID) focusing on integrated social and behaviour change communication (SBCC) in multiple health areas including malaria. The C4H project implemented: health messages promoting timely care-seeking that were included in radio spots and in a weekly drama/education radio series; vans mounted with loudspeakers disseminate messages in intervention areas; offline videos focusing on postnatal care, essential newborn care, seeking care for newborn illnesses, immunisation, and malaria prevention and treatment; a mobile application with key health messages, including prevention and care seeking; and complementary training of community health workers to conduct house-to-house education and outreach activities such as cue-cards and family health guide.

For the study, household surveys were conducted from 2016-2019 among female caregivers (N = 479) of children under five years of age with fever in Oromia, Amhara, Tigray, and Southern Nations, Nationalities, and Peoples Region (SNNPR). Prompt and delayed care-seeking were defined as seeking treatment within 24 hours or over 24 hours of symptom onset, respectively. Contextual factors explored included sociodemographic factors, household supply of insecticide-treated nets (ITNs), exposure to health messages, and household vulnerability (a measure of financial access to food, shelter, schooling, and medical treatment). Ideational factors included psychosocial factors related to care-seeking (knowledge, self-efficacy, response efficacy, attitudes, involvement in decision-making, and household social support).

While 95% of caregivers were aware of malaria, only 52% knew malaria symptoms, 60% knew the cause of malaria, and 24% knew measures to prevent malaria. Most caregivers had positive attitudes towards prompt care-seeking (90%). In addition, most caregivers had positive perceptions related to malaria, including perceived response efficacy for prompt care-seeking (96%) and malaria prevention (88%) and perceived self-efficacy to seek care promptly (87%) and prevent malaria (77%). Many (70%) caregivers reported involvement in decision-making, but few noted social support in the household from their partners (44%). Overall, less than half (44%) of caregivers possessed high care-seeking ideation.

The prevalence of fever among children under five years was 18% (ranging from 9% in Tigray to 34% in SNNPR). Overall, 45% of caregivers of children with fever sought care promptly, while 23% delayed care-seeking and 32% sought no care. Prompt care-seeking rates were higher among caregivers who had positive attitudes toward prompt care-seeking (48%), who were involved in decision-making (48%), or who perceived equitable gender norms in the community (65%). Caregivers with a high care-seeking ideation had increased odds of prompt care-seeking (adjusted odds ratio (aOR): 2.65; 95% confidence interval (CI): 1.74-4.02). Significant contextual factors included residence in the Oromia region (aOR: 2.99; 95% CI:1.40-6.41), caregivers age of 35-49 years (aOR: 0.49; 95% CI: 0.26–0.95), and residence in vulnerable households (aOR: 2.01; 95% CI: 1.28-3.18).

In short, this study demonstrated the overall role of psychosocial ideational factors. A key premise behind the ideation model is that people do not ordinarily take action, especially new action, until they have gained sufficient knowledge about it and its consequences, until they have a positive attitude toward it, and until they have talked to others about it and feel right about it. Considering this, the researchers recommend that:

• SBCC interventions should employ messaging that not only improves communities' knowledge about prompt care-seeking and its benefits but also promotes a positive attitude about prompt care-seeking, generates conversation and decision-making regarding prompt care-seeking, and enables communities to feel right about seeking care promptly.
• Behaviour change approaches should aim to promote supportive norms within the community and remove barriers to caregivers' self-efficacy and response efficacy regarding prompt care-seeking and other malaria related behaviour.
• Behaviour change approaches to promote use of health services are more impactful when complemented with interventions to ensure high-quality service delivery.
• Rather than just focusing on malaria, interventions in rural Ethiopia should employ a holistic approach to health and quality of life. Such an approach should employ a multi-sectoral lens and combine health, education, and gender empowerment interventions to improve the lives of community members.