This study is the most comprehensive one to date on the complex dynamics of behavioural decision-making related to malaria among populations in remote regions of Guyana most susceptible to the disease. It used an integrated conceptual model, known as ideation, to better understand decision-making about care-seeking, testing, and use of approved treatments for malaria prevention and mitigation. Studies show that multiple psychosocial, social, contextual, and structural factors can affect malaria-related behaviour, the ideational approach sheds light on how multiple factors often interact and have simultaneous influence over healthcare decisions. This allows for more nuanced and sophisticated communication strategies that are more likely to be effective for particular behaviours, audiences, and localized contexts.
Several common theories of behaviour change recognize that perceptions of threat and efficacy can be motivating; people who recognize that they are at risk and either have confidence in themselves and in available services or response options are more likely to be proactive in exercising healthy behaviours to address the disease threat. Also, living in a social environment where behavioural norms support protective actions and where people talk about the health issues they face and how to deal with them, can be reinforcing factors. In this study, we found that miners generally have relatively high perceptions of malaria risk and susceptibility, as well as relatively high knowledge about malarial disease, high self-confidence (self-efficacy) to protect themselves, and trust in available testing and treatment options (response efficacy). This would normally indicate favourable conditions for the exercise of positive care-seeking, malaria testing, and acceptance of approved treatments. On the other hand, this study also found that miners in Guyana had relatively low perceptions of normative support for these protective behaviours and reported relatively little communication with others about these issues. That suggests relatively weak social support to engage in these key protective behaviours, which could reduce otherwise positive motivation to act . This might be explained by the fact that miners are transitory and may have reduced chances of forming strong communities. Qualitative studies have also shown that self-medication among miners is borne out of conveniences as well as the belief that self-treatment works .
The advantage of the ideational analysis approach is that, while it allows inspection of the individual variables that go into a cumulative ideation score, it also emphasizes analysis of all of these factors simultaneously—recognizing the potential for interactions among them—as they apply to each of the three outcome behaviours of interest, while also controlling for the various demographic and contextual variables that define the local environments of miners in different regions and communities. When the cumulative ideation scores were calculated for each of the three outcome behaviours, we found relatively low care-seeking and treatment ideation, which normally would be linked to a lower probability of those behaviours. However, the ideation score varied across individuals and subgroups; it was higher among miners in Region 7 and among older, more educated, and more digitally connected miners. Other studies exploring ideation among key populations such as pregnant women and children also reported variations in ideation scores across and within subgroups [18, 19].
Miners who had higher care-seeking and testing ideation scores—indicating the presence of more positive ideational factors—were more likely to report those behaviours and were less likely to report self-medication rather than using approved treatment regimens. While certain individual ideational factors were more strongly associated with some outcomes than others (e.g., perceived normative support correlated with greater odds of getting tested, but not with care-seeking or rejecting self-medication), the cumulative ideation score was associated with greater adjusted marginal odds for each of the outcome behaviours. This suggests important programmatic value in communication strategies that emphasize multiple factors, rather than single factors, especially among miners with lower ideation to begin with. Most notably, this includes younger miners, those with less education, those with less access to mobile phones and other media, and those in Regions 1 and 8.
For example, according to this study, care-seeking messages should focus on increasing miners’ knowledge of malaria transmission and symptoms, as well as the conditions in the mining camps that make a miner susceptible to the disease. In contrast, messages about malaria testing should combine information about malaria knowledge, with encouragement of positive beliefs about malaria testing and volunteer testers, evidence about the effectiveness of testing as a protective strategy, reminders of how quick and easy it is to get a malaria test somewhere nearby, and the fact that one’s peers will support you if you get tested when you have a fever. This analysis can inform both media messaging as well as outreach efforts in remote regions, where mobile health workers can be guided with talking points about multiple factors to emphasize when discussing particular behaviours with their clients.
The study findings are being used in the implementation of SBC interventions for miners. The NMP and Breakthrough ACTION Guyana project are implementing a mass media campaign informed by human-centred design to address miners’ ideation related to care-seeking and treatment and increase demand for malaria related services . The campaign spans a variety of channels including radio, television, print materials, and social media. Central to the campaign is the use of a fictional miner’s experience and messages to increase risk perception, malaria knowledge, prompt care-seeking, and treatment adherence. This is accompanied by other influential persons in the mining community speaking out on the need for prompt and proper care-seeking for malaria. The mass media campaign is complemented by other interventions to ensure the delivery of high quality of testing and treatment services as the CCM initiative is being scaled up by the NMP. The Breakthrough ACTION Guyana project is complementing the NMP efforts by branding malaria testing and treatment locations with flags to increase the visibility of the CCM program. The volunteer testers are given certificates after training to promote their buy-in as well as validate them within their communities. The volunteer testers are also given job aids such as rapid counselling cards and a treatment pocket guide to improve the quality and accuracy of the service provided. Treatment adherence handouts are given to malaria positive clients that illustrate how the treatment works to encourage treatment adherence. An endline survey of miners is to be conducted to assess the impact of these interventions on miners’ behaviours and malaria outcomes.
While SBC interventions have been shown to improve miners' behaviours and potentially impact malaria outcomes , context-specific structural solutions remain crucial to the elimination of malaria in Guyana. The inaccessibility of hinterland regions, cost needed to reach the regions, the fact that houses in the hinterland are not conducive to indoor spraying and the emergence of insecticide resistance, has made the use of larvicides and indoor residual spraying unsustainable [24, 25]. Additionally, in-country migration due to humanitarian crises across Guyana’s borders have also contributed to the continuous transmission and endemicity of malaria. This study also has implications for efforts to eliminate malaria across the Guiana Shield, including Suriname , Brazil  and Venezuela , which have been also impeded by gold mining, high rates of self-medication due to inaccessible health facilities, and the importation of malaria cases . Efforts to ensure sustainability of programmatic interventions must be thoroughly explored. The role of public-private partnerships has proven to be a promising option .
This study has some limitations. First, the study relies wholly on self-reported data from miners, which may be prone to recall or social desirability bias. Only miners who were present in mining camps on the day of data collection were interviewed. The cross-sectional study design limits the ability to infer causality from the associations observed. The study was unable to explore treatment adherence among miners who were given malaria treatment due to low sample size and insufficient power. Also, the study did not explore supply side factors occurring at the malaria service provision sites, which may likely influence miners’ behaviours. Such factors may include stockout of RDTs and malaria drugs and inadequate technical and interpersonal skills of the service providers.