In 2019, Ethiopia achieved the Global Technical Strategy for Malaria 2020 target of a 40% reduction in malaria case incidence and reduction in mortality rate. While Ethiopia is characterized by an overall low malaria prevalence rate, over half of Ethiopians remain vulnerable to malaria with 27 million people living in high-transmission zones (more than one case per 1,000 population) and over 250,000 confirmed cases of malaria in 2019.
Appropriate management of fever cases, insecticide-treated net (ITN) use, and intermittent presumptive treatment of malaria in pregnancy remain key to malaria control. The National Malaria Control and Elimination Program (NMCEP) has made great strides in reducing malaria burden and charting a path to elimination, including the roll-out of rapid diagnostic testing (RDT) and artemisinin-based combination therapy at the community level. Prompt care-seeking (defined as seeking care within the same day or next day of fever onset) is a key behavior to ensuring proper case management of suspected and confirmed malaria cases.
NMCEP aims to ensure all suspected malaria cases are diagnosed using either RDT or microscopy within 24 hours of fever onset and all households living in malaria-endemic areas have the knowledge, attitudes, and practices necessary for adopting appropriate health-seeking behavior for malaria prevention and control. While the 2015 National Malaria Indicator Survey demonstrated that advice or treatment was sought for half of all children with fever, the number of children of fever for whom care was promptly sought is unknown.
Considering NMCEP’s objectives and the critical role of prompt care-seeking in ensuring proper diagnosis and treatment of malaria, relevant stakeholders need to understand the factors influencing care-seeking behaviors for children with fever, particularly at the caregiver level. Specifically, to what extent Ethiopian caregivers who seek care promptly may differ from those who delay seeking care and from those who never seek care at all.
Of particular interest is the role of caregivers’ psychosocial factors, defined as social, cultural, environmental phenomena, and other influences that may affect their behavior.Psychosocial factors play an indubitable role in health and behavior change[5–7]. Recent studies in Ethiopia have explored the psychosocial factors associated with prompt care-seeking[8–11]. A facility-based study of a predominantly adult patient population in the Amhara region revealed that about half of febrile patient participants sought treatment within 24 hours of fever onset, and this was higher among patients who were knowledgeable about malaria prevention and transmission, close to a health center, or had a family size of less than five household members.
In Tigray, care-seeking was delayed among low-income patients and those without health insurance. In Dera, northwest Ethiopia, income, community-based health insurance, previous history of malaria infection, decision-making and distance from the facility were determinants of delay in seeking treatment for malaria. In addition, a community based study in Jimma found higher rates of prompt care-seeking among Muslim and uneducated respondents.
However, few studies have specifically explored factors influencing prompt care-seeking among caregivers of febrile children under five years of age. This warrants deeper research, as children under five remain more vulnerable to malaria complications. Community studies demonstrated low levels of caretakers' understanding of malaria in specific localities. Specifically, in the Mandura district of West Ethiopia, a considerable number of caregivers first consulted traditional healers and tried home treatment and thus, sought treatment late. Caregivers’ ages,, malaria knowledge, perceived susceptibility to malaria, and perceived barrier to seek treatment, and if caregivers lived in rural villages, were important factors in seeking health care.
This study seeks to explore the spectrum of prompt care-seeking behavior and associated psychosocial factors among female caregivers of children under five with fever in rural Ethiopia: Oromia; Amhara; Southern Nations, Nationalities, and Peoples Region (SNNPR); and Tigray. Study findings can inform the design of evidence-based community engagement approaches that appropriately target caregivers in these regions and other similar settings.
Several conceptual frameworks have explored psychosocial factors influencing health behavior. As shown in Figure 1, the ideation framework developed by Kincaid serves as the underpinning for this manuscript[13, 14]. The concept of ideation has proven useful in understanding individual-level psychosocial factors affecting malaria-specific outcomes including ITN use[15, 16] and appropriate care-seeking. The ideation framework is drawn from various behavioral theories and recognizes that most behavioral decisions are driven by psychosocial factors including cognitive, emotional, and social factors. Cognitive factors include knowledge of disease symptoms; transmission and prevention; and beliefs, 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.
This study uses the ideation framework to understand the psychosocial factors associated with care-seeking among caregivers of febrile children under five. The study explores a limited number of ideational psychosocial factors related to care-seeking (malaria-related knowledge, self-efficacy, response-efficacy, beliefs, decision-making agency, and social support in the household) against the backdrop of overarching contextual psychosocial factors (demographics, physical environment, and access to resources) seen among caregivers in rural Ethiopia.