Malaria Treatment Seeking Research Articles

Improving malaria case management with artemisinin-based combination therapies and malaria rapid diagnostic tests in private medicine retail outlets in sub-Saharan Africa: A systematic review.

Private medicine retailers (PMRs) such as pharmacies and drug stores account for a substantial share of treatment-seeking for fever and malaria, but there are widespread concerns about quality of care, including inadequate access to malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs). This review synthesizes evidence on the effectiveness of interventions to improve malaria case management in PMRs in sub-Saharan Africa (PROSPERO #2021:CRD42021253564). We included quantitative studies evaluating interventions supporting RDT and/or ACT sales by PMR staff, with a historical or contemporaneous control group, and outcomes related to care received. We searched Medline Ovid, Embase Ovid, Global Health Ovid, Econlit Ovid and the Cochrane Library; unpublished studies were identified by contacting key informants. We conducted a narrative synthesis by intervention category. We included 41 papers, relating to 34 studies. There was strong evidence that small and large-scale ACT subsidy programmes (without RDTs) increased the market share of quality-assured ACT in PMRs, including among rural and poorer groups, with increases of over 30 percentage points in most settings. Interventions to introduce or enhance RDT use in PMRs led to RDT uptake among febrile clients of over two-thirds and dispensing according to RDT result of over three quarters, though some studies had much poorer results. Introducing Integrated Community Case Management (iCCM) was also effective in improving malaria case management. However, there were no eligible studies on RDT or iCCM implementation at large scale. There was limited evidence that PMR accreditation (without RDTs) increased ACT uptake. Key evidence gaps include evaluations of RDTs and iCCM at large scale, evaluations of interventions including use of digital technologies, and robust studies of accreditation and other broader PMR interventions.

Factors influencing delay in malaria treatment seeking at selected public health facilities in South Gonder, Ethiopia

Early and prompt treatment-seeking for malaria is necessary to reduce the progression of the disease to its severe forms and the associated mortality. Various studies have indicated that treatments sought for malaria were not always within the recommended timeframe. Therefore, this study aims to assess factors influencing delay in malaria treatment seeking at public health facilities in South Gonder, Ethiopia. An unmatched case–control study was conducted among 322 individuals, comprising 161 cases and 161 controls, who were randomly selected malaria patients visiting public health facilities in South Gonder District, Ethiopia, from May 20/2022 to June 25/2022. An interviewer-administered questionnaire was used to collect data, which were subsequently cleaned and entered into Epi data. Descriptive statistics were performed, and variables with a p-value of ≤ 0.25 from the bivariate analysis were included in a multivariable logistic regression model. Significant variables with a p-value of < 0.05 were retained in the multivariable model. Patients who were unable to read and write [AOR = 3.47 (1.01–11.9)], fear of side effects of malaria treatment drugs [AOR = 1.89 (1.04–3.42)], lack of access to health education malaria disease and its treatment [AOR = 1.93 (1.02–3.65)], lack of transportation access [AOR = 4.70 (1.73–12.7)], not membership of community-based health insurance [AOR = 2.5 (1.3–4.82)] and lack of confidence on malaria care health facility providing [AOR = 2.14 (1.06–4.29)], were found to be determinants of treatment-seeking delay among malaria patients. In Summary, this study revealed significant associations between delays in seeking malaria treatment and factors such as educational status (those who were unable to read and write), malaria drug side effects, health education on malaria, transportation access, CBHI membership, and confidence in health malaria care. it is recommended that targeted interventions and awareness campaigns be implemented to address these determinants, promoting prompt and effective malaria treatment-seeking behavior in the studied population.

Community and health worker perspectives on malaria in Meghalaya, India: covering the last mile of elimination by 2030

BackgroundMalaria remains a public health problem in regions of Northeastern India because of favourable bio-geographic transmission conditions, poor access to routine healthcare, and inadequate infrastructure for public health and disease prevention. This study was undertaken to better understand community members’ and health workers’ perceptions of malaria, as well as their knowledge, attitudes, and prevention practices related to the disease in Meghalaya state.MethodsThe study included participants from three malaria endemic districts: West Khasi Hills, West Jaiñtia Hills, and South Garo Hills from 2019 to 2021. A total of 82 focus group discussions (FGD) involving 694 community members and 63 in-depth interviews (IDI) with health personnel and traditional healers residing within the three districts were conducted. A thematic content analysis approach was employed, using NVivo12 software for data management.ResultsMost participants reported a perceived reduction in malaria during recent years, attributing this to changes in attitudes and behaviours in health seeking, and to more effective government interventions. Local availability of testing and treatment, and an improved, more responsive health system contributed to changing attitudes. Long-lasting insecticidal nets (LLINs) were largely preferred over indoor residual spraying (IRS), as LLINs were perceived to be effective and more durable. Community members also reported using personal protective measures such as applying repellents, burning neem tree leaves, straw/egg trays, wearing long sleeve clothes, and applying ointments or oils to protect themselves from mosquito bites. While most participants acknowledged the role of mosquitoes in malaria transmission, other conditions that are not mosquito-borne were also attributed to mosquitoes by some participants. The communities surveyed have largely shifted from seeking treatment for malaria from traditional healers to using public facilities, although some participants reported switching between the two or using both simultaneously. Improved understanding of cerebral malaria, which some participants previously attributed to mental illness due to ‘bad spirits’, is an example of how cultural and ritualistic practices have changed.ConclusionThe findings reveal diverse perceptions among community members regarding malaria, its prevention, practices to prevent mosquito-transmitted diseases, and their opinions about the healthcare system. A key finding was the shift in malaria treatment-seeking preferences of community members from traditional healers to the public sector. This shift highlights the changing dynamics and increasing acceptance of modern healthcare practices for malaria treatment and prevention within tribal and/or indigenous communities. By recognizing these evolving attitudes, policymakers and healthcare providers can better tailor their interventions and communication strategies to more effectively address ongoing needs and concerns as India faces the ‘last mile’ in malaria elimination.

Factors affecting delays in seeking treatment among malaria patients during the pre-certification phase in China

BackgroundDelays in malaria treatment can not only lead to severe and even life-threatening complications, but also foster transmission, putting more people at risk of infection. This study aimed to investigate the factors influencing treatment delays among malaria patients and their health-seeking behaviour.MethodsThe medical records of 494 patients diagnosed with malaria from 6 different malaria-endemic provinces in China were analysed. A bivariate and multivariable regression model was used to investigate the association between delays in seeking treatment and various factors. A Sankey diagram was used to visualize the trajectories of malaria patients seeking medical care. Total treatment delays were categorized as patient delays and doctor delays.ResultsThe incidence of total delays in seeking malaria treatment was 81.6%, of which 28.4% were delayed by patients alone and 34.8% by doctors alone. The median time from the onset of symptoms to the initial healthcare consultation was 1 day. The median time from the initial healthcare consultation to the conclusive diagnosis was 2 day. After being subjected to multiple logistic regression analysis, living in central China was less likely to experience patient delays (OR = 0.43, 95% CI 0.24–0.78). The factors significantly associated with the lower likelihood of doctor delays included: age between 30 to 49 (OR = 0.43, 95% CI 0.23–0.81), being single/divorce/separated (OR = 0.48, 95% CI 0.24–0.95), first visiting a county-level health institution (OR = 0.25, 95% CI 0.14–0.45), first visiting a prefectural health institution (OR = 0.06, 95% CI 0.03–0.12) and first visiting a provincial health institution (OR = 0.05, 95%CI 0.02–0.12). Conversely, individuals with mixed infections (OR = 2.04, 95% CI 1.02–4.08) and those experiencing periodic symptoms (OR = 1.71, 95% CI 1.00–2.92) might face increased doctor delays. Furthermore, higher financial burden and complications were found to be associated with patient delays. Doctor delays, in addition to incurring these two consequences, were associated with longer hospital stays.ConclusionThere was a substantial delay in access to health care for malaria patients before China was certified malaria free. Region, marital status, periodic symptoms and the level of health institutions were factors contributing to delays in treatment-seeking among malaria patients.

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

BackgroundAppropriate 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.MethodsA 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.ResultsAmong 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).ConclusionsTSB 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.

Plasmodium falciparum infection and naturally acquired immunity to malaria antigens among Ghanaian children in northern Ghana

BackgroundThe surge in malaria cases and deaths in recent years, particularly in Africa, despite the widespread implementation of malaria-control measures could be due to inefficiencies in malaria control and prevention measures in malaria-endemic communities. In this context, this study provides the malaria situation report among children in three Municipalities in Northern Ghana, where Seasonal Malaria Chemotherapy (SMC) is implemented by Ghana Health Service (GHS). MethodsA cross-sectional household survey was carried out to assess the malaria knowledge, attitudes, and practices (KAP) and malaria prevalence in 394 households in 13 rural communities in the Kumbugu, Nanton and Tolon Municipalities, Northern Region, Ghana. This was followed by screening for P. falciparum infection with anti-HRP2 RDT and PCR among children 1–17 years in the households. Plasma levels of IgG specific for crude P. falciparum antigen (3D7) and four recombinant malaria antigens (CSP, GLURP, MSP3, and Pfs230) were assessed by ELISA. The malaria and parasitaemia data were converted into frequency and subgroup proportions and disaggregated by study sites and demographic information of the participants. The ELISA data was converted to arbitrary units (AU) and similarly compared across study sites and demographic information. ResultsThe P. falciparum infection rate and frequency of malaria were high in the study areas with significant age-dependent and inter-community differences, which were reflected by differences in plasma levels of P. falciparum-specific IgG. Over 60% of households reported the use of bed nets and indoor insecticide sprays/coils, and 14% mentioned bush clearing around homes (14%) as malaria preventive measures. Community health centres were the preferred place for households (88%) to seek malaria treatment but over-the-counter drug stores were the major source (66%) of their antimalarials. Overall, malaria preventive and treatment practices were sub-optimal. ConclusionsP. falciparum infection and malaria are still high in the studied communities, indicating that preventive and control measures against the disease in the region remain inadequate. Efforts to ensure high SMC compliance and to improve preventative and treatment practices thus seem cost-beneficial “low-hanging fruits” in the fight against malaria in the Northern Region of Ghana.

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.

User fee exemption and malaria treatment-seeking for children under five in a Cameroonian health district: a cross-sectional study

BackgroundIn Cameroon, malaria contributes significantly to the morbidity and mortality of children under 5 years old. In order to encourage adequate treatment-seeking in health facilities, user fee exemptions for malaria treatment have been instituted. However, many children are still brought to health facilities in the late stage of severe malaria. This study sought to determine the factors affecting the hospital treatment-seeking time of guardians of children under 5 years within the context of this user fee exemption.MethodsThis was a cross-sectional study conducted at three randomly selected health facilities of the Buea Health District. A pre-tested questionnaire was used to collect data on the treatment-seeking behaviour and time of guardians, as well as potential predictors of this time. Hospital treatment sought after 24 h of noticing symptoms was denoted as delayed. Continuous variables were described using medians while categorical variables were described using percentages. A multivariate regression analysis was used to determine the factors affecting malaria treatment-seeking time of guardians. All statistical tests were done at a 95% confidence interval.ResultsMost of the guardians made use of pre-hospital treatments, with self-medication being practiced by 39.7% (95% CI 35.1–44.3%) of them. A total of 193 (49.5%) guardians delayed seeking treatment at health facilities. Reasons for delay included financial constraints and watchful waiting at home, during which guardians waited and hoped their child could get better without requiring medicines. Guardians with estimated monthly household incomes denoted as low/middle were significantly more likely (AOR 3.794; 95% CI 2.125–6.774) to delay seeking hospital treatment. The occupation of guardians was another significant determinant of treatment-seeking time (AOR 0.042; 95% CI 0.003–0.607). Also, guardians with tertiary education were less likely (AOR 0.315; 95% CI 0.107–0.927) to delay seeking hospital treatment.ConclusionsThis study suggests that despite user fee exemption, other factors such as educational and income levels of guardians affect malaria treatment-seeking time for children aged under five. Therefore, these factors should be considered when enacting policies aimed at increasing access of children to health facilities.

Community case management of malaria in Western Kenya: performance of community health volunteers in active malaria case surveillance

BackgroundIn western Kenya, not all malaria cases are reported as stipulated in the community case management of malaria (CCMm) strategy. This underreporting affects the equity distribution of malaria commodities and the evaluation of interventions. The current study aimed to evaluate the effectiveness of community health volunteers’ active case detection and management of malaria in western Kenya.MethodsCross-sectional active case detection (ACD) of malaria survey was carried out between May and August 2021 in three eco-epidemiologically distinct zones in Kisumu, western Kenya: Kano Plains, Lowland lakeshore and Highland Plateau. The CHVs conducted biweekly ACD of malaria household visits to interview and examine residents for febrile illness. The Community Health Volunteers (CHVs) performance during the ACD of malaria was observed and interviews done using structured questionnaires.ResultsOf the total 28,800 surveyed, 2597 (9%) had fever and associated malaria symptoms. Eco-epidemiological zones, gender, age group, axillary body temperature, bed net use, travel history, and survey month all had a significant association with malaria febrile illness (p < 0.05). The qualification of the CHV had a significant influence on the quality of their service. The number of health trainings received by the CHVs was significantly related to the correctness of using job aid (χ2 = 6.261, df = 1, p = 0.012) and safety procedures during the ACD activity (χ2 = 4.114, df = 1, p = 0.043). Male CHVs were more likely than female CHVs to correctly refer RDT-negative febrile residents to a health facility for further treatment (OR = 3.94, 95% CI = 1.85–5.44, p < 0.0001). Most of RDT-negative febrile residents who were correctly referred to the health facility came from the clusters with a CHV having 10 years of experience or more (OR = 1.29, 95% CI = 1.05–1.57, p = 0.016). Febrile residents in clusters managed by CHVs with more than 10 years of experience (OR = 1.82, 95% CI = 1.43–2.31, p < 0.0001), who had a secondary education (OR = 1.53, 95% CI = 1.27–1.85, p < 0.0001), and were over the age of 50 (OR = 1.44, 95% CI = 1.18–1.76, p < 0.0001), were more likely to seek malaria treatment in public hospitals. All RDT positive febrile residents were given anti-malarial by the CHVs, and RDT negatives were referred to the nearest health facility for further treatment.ConclusionsThe CHV’s years of experience, education level, and age had a significant influence on their service quality. Understanding the qualifications of CHVs can assist healthcare systems and policymakers in designing effective interventions that assist CHVs in providing high-quality services to their communities.

Treatment Seeking Behavior of Pregnant Women about Malaria in Muzaffargard

Malaria during pregnancy and childhood is the major public health problem and about half of the population is at risk of developing malaria in the world. During pregnancy, it causes severe anemia, low birth weight babies, abortion and many other severe complications. Knowledge plays main role to prevent this disease and therefore in this study health seeking behavior of pregnant women is explored to determine frequency of malaria suspected cases and the reasons for non-utilization of Government health facilities by pregnant women. A total 312 pregnant women were selected through multistage random sampling. A structured questionnaire was used to know about the knowledge and practice of pregnant women about malaria. A survey was conducted Longmalan Village of Muzaffargard. Data was collected and analyzed by using SPSS version 20. Knowledge about malaria was found poor in the majority of the respondents. The major sources of treatment was private health facilities. The major reasons of non-utilization of public health facilities were poor accessibility to transport, lack of trust on public medical providers, and their bad attitude. On the basis of these findings, it was concluded that malaria knowledge has shown to be an important factor for prevention and treatment seeking practices about malaria health education and literacy promotion should strengthen the knowledge about malaria prevention and treatment seeking behavior.

Clinical malaria incidence and health seeking pattern in geographically heterogeneous landscape of western Kenya

BackgroundMalaria remains a public health problem in Kenya despite sustained interventions deployed by the government. One of the major impediments to effective malaria control is a lack of accurate diagnosis and effective treatment. This study was conducted to assess clinical malaria incidence and treatment seeking profiles of febrile cases in western Kenya.MethodsActive case detection of malaria was carried out in three eco-epidemiologically distinct zones topologically characterized as lakeshore, hillside, and highland plateau in Kisumu County, western Kenya, from March 2020 to March 2021. Community Health Volunteers (CHVs) conducted biweekly visits to residents in their households to interview and examine for febrile illness. A febrile case was defined as an individual having fever (axillary temperature ≥ 37.5 °C) during examination or complaints of fever and other nonspecific malaria related symptoms 1–2 days before examination. Prior to the biweekly malaria testing by the CHVs, the participants' treatment seeking methods were based on their behaviors in response to febrile illness. In suspected malaria cases, finger-prick blood samples were taken and tested for malaria parasites with ultra-sensitive Alere® malaria rapid diagnostic tests (RDT) and subjected to real-time polymerase chain reaction (RT-PCR) for quality control examination.ResultsOf the total 5838 residents interviewed, 2205 residents had high temperature or reported febrile illness in the previous two days before the visit. Clinical malaria incidence (cases/1000people/month) was highest in the lakeshore zone (24.3), followed by the hillside (18.7) and the highland plateau zone (10.3). Clinical malaria incidence showed significant difference across gender (χ2 = 7.57; df = 2, p = 0.0227) and age group (χ2 = 58.34; df = 4, p < 0.0001). Treatment seeking patterns of malaria febrile cases showed significant difference with doing nothing (48.7%) and purchasing antimalarials from drug shops (38.1%) being the most common health-seeking pattern among the 2205 febrile residents (χ2 = 21.875; df = 4, p < 0.0001). Caregivers of 802 school-aged children aged 5–14 years with fever primarily sought treatment from drug shops (28.9%) and public hospitals (14.0%), with significant lower proportions of children receiving treatment from traditional medication (2.9%) and private hospital (4.4%) (p < 0.0001). There was no significant difference in care givers' treatment seeking patterns for feverish children under the age of five (p = 0.086). Residents with clinical malaria cases in the lakeshore and hillside zones sought treatment primarily from public hospitals (61.9%, 60/97) traditional medication (51.1%, 23/45) respectively (p < 0.0001). However, there was no significant difference in the treatment seeking patterns of highland plateau residents with clinical malaria (p = 0.431).The main factors associated with the decision to seek treatment were the travel distance to the health facility, the severity of the disease, confidence in the treatment, and affordability.ConclusionClinical malaria incidence remains highest in the Lakeshore (24.3cases/1000 people/month) despite high LLINs coverage (90%). The travel distance to the health facility, severity of disease and affordability were mainly associated with 80% of residents either self-medicating or doing nothing to alleviate their illness. The findings of this study suggest that the Ministry of Health should strengthen community case management of malaria by providing supportive supervision of community health volunteers to advocate for community awareness, early diagnosis, and treatment of malaria.

Household costs associated with seeking malaria treatment during pregnancy: evidence from Burkina Faso and The Gambia

BackgroundMalaria in pregnancy remains a major health threat in sub-Saharan Africa to both expectant mothers and their unborn children. To date, there have been very few studies focused on the out of pocket costs associated with seeking treatment for malaria during pregnancy.MethodsA cross-sectional survey was undertaken in Burkina Faso and The Gambia to estimate the direct and indirect costs associated with outpatient consultations (OP) and inpatient admissions (IP). Direct costs were broken down into medical (admission fees, drug charges, and laboratory fees), and non-medical (transportation and food). Indirect costs reflected time lost due to illness. In total, 220 pregnant women in Burkina Faso and 263 in The Gambia were interviewed about their treatment seeking decisions, expenditure, time use and financial support associated with each malaria episode.ResultsIn Burkina Faso 6.7% sought treatment elsewhere before their OP visits, and 27.1% before their IP visits. This compares to 1.3% for OP and 25.92% for IP in The Gambia. Once at the facility, the average direct costs (out of pocket) were 3.91US$ for an OP visit and 15.38US$ of an IP visit in Burkina Faso, and 0.80US$ for an OP visit and 9.19US$ for an IP visit in The Gambia. Inpatient direct costs were driven by drug costs (9.27US$) and transportation costs (2.72US$) in Burkina Faso and drug costs (3.44 US$) and food costs (3.44 US$) in The Gambia. Indirect costs of IP visits, valued as the opportunity cost of time lost due to the illness, were estimated at 11.85US$ in Burkina Faso and 4.07US$ in The Gambia. The difference across the two countries was mainly due to the longer time of hospitalization in Burkina Faso compared to The Gambia. In The Gambia, the vast majority of pregnant women reported receiving financial support from family members living abroad, most commonly siblings (65%).ConclusionsHigh malaria treatment costs are incurred by pregnant women in Burkina Faso and The Gambia. Beyond the medical costs of fees and drugs, costs in terms of transport, food and time are significant drivers. The role of remittances, particularly their effect on accessing health care, needs further investigation.

Malaria epidemic and transmission foci in highland of Kisii, western Kenya

BackgroundThe vulnerable population within the malaria epidemic zone remains at risk of increased burden and fatality. This is because of unpreparedness and overstretching of healthcare capacity in the event of a full-fledged epidemic. The purpose of this study was to determine the prevalence of microscopic and submicroscopic infections, as well as map specific Plasmodium transmission foci, in the malaria epidemic-prone zone of Kisii highland. MethodologyPatients seeking malaria treatment at Eramba health facility in the epidemic-prone zone of Kisii highland were enrolled in the study. Malaria outpatient data for the entire month of May were also included in the analysis. Patients' finger prick blood smears were examined for microscopic infections, while a real-time polymerase chain reaction targeting the Plasmodium species 18S rRNA gene was used to detect the presence of submicroscopic infections on DNA extracted from dry blood spots. ResultsBased on outpatient data, the malaria positivity rate was 20.7% (231/1115, 95% CI, 0.18–0.23). The positivity rate varied significantly by age group (χ2 = 75.05, df 2, p < 0.0001). Children under the age of five had the highest positivity rate (27.8%, 78/281), followed by children aged 5–15 years (19.4%, 69/356), and individuals aged 15 years and above (17.6%, 84/478). Out of the 102 patients recruited, the positivity rate by microscopy was 57.8% (59/102) and 72.5% (74/102) by RT-PCR. Most of the microscopic infections (40.7%, 24/59) were from Morara and Nyabikondo villages in Rioma and Kiomooncha sublocations, respectively. The submicroscopic prevalence was 14.7% (15/102) and was observed only in patients from high-infection villages in Rioma (15.8%, 9/57) and Kiomooncha (16.2%, 6/37) sublocations. Across gender and age groups, females (19.7%, 12/61) and patients aged 15 years and above (21.1%, 8/38) had high levels of submicroscopic infections. There were two mixed infections of P. falciparum/P. malariae and P. falciparum/P. ovale, both from patients residing in Kiomooncha sublocation. ConclusionPlasmodium falciparum infections remained relatively high in the Marani subcounty. Infections were concentrated in two villages, which could serve as a target for future public health intervention, particularly during a malaria epidemic.

Bed net use and malaria treatment-seeking behavior in artisanal gold mining and sugarcane growing areas of Western Kenya highlands

Provision of the bed net in Sub-Saharan Africa has substantially resulted in the decrease in malaria incidences in the region. However, malaria still ravages these regions causing significant deaths. This situation has been attributed to socio-economic inequalities that reduce access to the net, failure to seek treatment, and poor antimalarial drug use. Information about these factors in malaria control in Western Kenya highlands is not clearly documented. This study sought to find out bed net availability and use, treatment-seeking, and antimalarial drug use behavior in two rural communities. The study was a qualitative-quantitative baseline cross-sectional survey carried out in two rural villages in Western Kenya highlands in November – December 2018. Focus group discussion, a semi-structured questionnaire, and in-depth interviews were conducted in 736 households to determine: socio-demographic characteristics; bed net availability and use; action taken when sick with malaria, and antimalarial drug usage. Socio-demographic characteristics and the responses of the participants were expressed as percentages. Dependent and independent variables were cross-tabulated for calculation of OR and association was tested using Pearson Chi-square at 95% CI and a p ≤ 0.05 was considered significant. Ninety-three percent of the respondents had used the net the previous night, females (56.50%) constituted the majority of respondents, going to health facility (84.26%) was the preferred action taken when a person had malaria, Artemether Lumefantrine (90.19%), and a pain killer was the most cited drug, 22.96% of the responders reported to have failed to complete antimalarial dose saying that they had recovered from the malaria bout and 9.80% reported to re-use the remaining part of the dosage. This was the first study in mining and sugarcane growing communities in Western Kenya Highlands that has shown that there was no association between socio-demographic parameters and bed net use, action taken when having malaria, and adherence to drug use. The two rural communities have the bed net and know its use. They have good knowledge of malaria and seek treatment whenever they saw malaria signs. The study also reported that the action the sick person took when they had a malaria bout, the drug they got from the health facility, or failure to complete an AL dosage regimen was not associated with socio-demographic characteristics of the responder. These findings raise the need for further qualitative studies in other settings to accept or deny that there was no association between socio-demographics and action taken when hit with malaria bout, the drug used, and failure to complete drug dosage.

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

The World Health Organization recommends seeking medical treatment within 24 hours after transmission of malaria to reduce the risk of severe complications and its onwards spread. However, in some parts of Indonesia, including East Nusa Tenggara Province (ENTP), this adherence is not achieved for a range of reasons including delays in visiting health centres. This study aims to determine factors related to the poor understanding of appropriate malaria treatment-seeking behaviour (AMTSB) of rural adults in ENTP. AMTSB was defined as seeking treatment at professional health facilities within 24 hours of the onset of malaria symptoms. A cross-sectional study was conducted in the East Sumba, Belu, and East Manggarai district of ENTP between October and December 2019. A multi-stage cluster sampling procedure was applied to enrol 1503 participants aged between 18 and 89 years of age. Data were collected through face-to-face interviews. Multivariable logistic regression analyses were used to assess significant factors associated with the poor understanding of AMTSB. Eighty-six percent of participants were found to be familiar with the term malaria. However, poor understanding level of AMTSB in rural adults of ENTP achieved 60.4% with a 95% confidence interval (CI): 56.9-63.8. Poor understanding of AMTSB was significantly higher for adults with no education (adjusted odds ratio (AOR) 3.42, 95% CI: 1.81, 6.48) compared to those with a diploma or above education level; having low SES (AOR: 1.87, 95% CI: 1.19, 2.96) compared to those having high SES; residing at least three kilometres (km) away from the nearest health facilities (AOR: 1.73, 95% CI: 1.2, 2.5) compared to those living within one km from the nearest health service; and working as farmer (AOR: 1.63, 95% CI: 1.01-2.63) compared to those working at government or non-government sector. Whilst, other factors such as ethnicity and family size were not associated with the poor understanding of AMTSB. The proportion of rural adults having a poor understanding of AMTSB was high leading to ineffective implementation of artemisinin-based combination therapies as the method to treat malaria in ENTP. Improving awareness of AMTSB for rural adults having low level education, low SES, working as a farmer, and living at least three km from the nearest health facilities is critical to support the efficacy of malaria treatment in ENTP. This method will support the Indonesian government's objective to achieve malaria elimination by 2030.

Malaria Prevalence and Treatment Seeking Behaviour of Campus Students in Mkpat Enin, Akwa Ibom State, Nigeria

Background: Malaria is still thriving despite efforts to eradicate the disease. This study aimed to determine the prevalence of malaria and treatment-seeking behaviour among university students in Ikot Akpaden campus of Akwa Ibom State University Methods: A cross-sectional study on 700 undergraduate students randomly selected was carried out between July to December 2017 in Akwa Ibom State University. Structured questionnaires were administered to collect data. Microscopy and Rapid Diagnostic Tests (RDT) were done to determine parasitaemia for students who voluntarily consented to be tested. Chi-square test at P&lt; 0.05 was used to evaluate the prevalence of malaria and the differences in the student’s attitude on malaria treatment and prevention practices. Results: Of the 500 students who filled the questionnaire, 100 students consented to undergo the test, 56 (56%) were males, while 44 (44%) were females. Only15 students (17.86%) were positive for both microscopy and RDT. Malaria prevalence by microscopy (84%) was significantly higher than RDT (27%). Fever and head-ache were the most common symptoms recorded. RDT had a sensitivity of 17.86%, a specificity of 25%, a positive predictive value of 55.56%, and a negative predictive value of 5.48%. Conclusion: This study revealed a higher prevalence of malaria by microscopy than RDT among the students, indicating that the use of RDTs is limited. RDTS may have more usefulness in remote areas, but microscopy remains the reference technique. Overall, 96.2% knew about malaria while 85.3% knew mosquito bites cause malaria. The majority, 69.2%, of participants go for malaria test as the first action when malaria is suspected, 83% use antimalarial combination therapy medication, and 62.6% sought treatment of malaria immediately.

Human-centered design process and solutions to promote malaria testing and treatment seeking behavior in Guyana hinterlands

BackgroundMalaria is a persistent public health challenge among miners and other hard-to-reach populations in Guyana’s hinterland, specifically in Regions 1, 7, 8, and 9. Despite an overall decrease in malaria prevalence throughout Guyana, it remains common among mining populations whose work conditions both contribute toward malaria transmission and make it difficult to seek timely, Ministry of Health (MoH) approved malaria testing and treatment services. In an effort to develop innovative approaches to address this public health challenge, an interdisciplinary team of public health professionals, designers, and mining organizations collaborated using a human-centered design (HCD) process facilitated by the USAID-funded Breakthrough ACTION Guyana project in partnership with the MoH.MethodsThis paper describes two phases: [1] Define and [2] Design & Test. In the Define phase, following a literature review, we conducted 108 qualitative interviews with miners, camp managers, trained malaria testers, health workers, and other key stakeholders to understand experiences and challenges when seeking malaria testing and treatment services. These interviews were synthesized into 11 insights on issues such as risk perception, malaria knowledge, preventive behaviors, traditional and self-treatment, adherence to the correct treatment, testing, and coordination and communication gaps. From these insights, during the Design & Test phase, we developed 33 “How might we…?” questions which led to 792 ideas, of which eight emergent concepts were prototyped and refined in the field with 145 miners, camp managers, and stakeholders.ResultsThe five final prototypes included: “Little Mosquito, Big Problem” social behavior change campaign; rapid counseling cards; branded malaria testing and treatment services; innovations in treatment adherence; and a participants, content, and logistics approach.ConclusionWhen applying HCD to public health issues, there are both opportunities and challenges to reconcile gaps that may exist between the two disciplines. However, HCD provides additional tools and mindsets to generatively work with migrant and mobile mining communities to encourage malaria testing and treatment services.

Finding the right balance: implementation of public\u2013private partnership in artemisinin-based combination therapy provision in Manokwari, Indonesia

BackgroundIndonesia is the second country with the highest number of malaria cases in Southeast Asia. Private health providers including community pharmacies often become the first point of care for the population seeking malaria treatment; however, public–private partnerships for malaria control are not widely implemented. This paper explores the acceptability of a public-private partnership program on the provision of subsidized artemisinin-based combination therapies (ACTs) in community pharmacies from the perspectives of private health providers, patients, and program implementers.MethodsThe study was conducted in Manokwari District in West Papua Province, one of the highest endemic districts in Indonesia. Qualitative methods using interviews and focus group discussions (FGDs) were employed to explore the following dimensions of acceptability: affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness, and self-efficacy. Study participants were program implementers, private health providers, and pharmacy clients. Audio-recorded interviews were transcribed and analyzed using thematic analysis. Secondary data on malaria cases and the use of ACTs reported by community pharmacies were also recorded.ResultsOnly one-fourth of the total community pharmacies in Manokwari participated in the partnership, suggesting low coverage of the program. The proportion of malaria cases reported by community pharmacies increased from 6.9% in 2018 to 30.7% of cases. Most participants had a positive attitude towards the program, which might be associated with the perceived effectiveness of the partnership in improving access to ACTs. Despite the good understanding of the intervention by the participating pharmacies, limited involvement of private physicians often resulted in non-standardized treatment practices. The partnership also imposed a burden on private health providers in terms of human resources and time which entailed significant opportunity costs. A number of ethical issues might undermine the equity of access to ACTs.ConclusionDespite the positive attitude to the partnership, the perceived burden might outweigh the tangible benefits, posing threats to scaling up the intervention and sustainability. Innovations to simplify the administrative procedures in combination with performance-based incentives are needed to improve implementation. Engagement of patients and physicians is needed to increase the effectiveness of the partnership.

Costs and barriers faced by households seeking malaria treatment in the Upper River Region, The Gambia

BackgroundMalaria transmission in The Gambia decreased substantially over the last 20 years thanks to the scale-up of control interventions. However, malaria prevalence is still relatively high in eastern Gambia and represents both a health and a financial burden for households. This study aims to quantify the out-of-pocket costs and productivity losses of seeking malaria treatment at household level.MethodsA household survey was carried out through in-person interviews. Respondents were asked about malaria prevention methods, their treatment-seeking behaviour, and any costs incurred for transport, services, food, and/or overnight stays. A bottom-up costing approach was used to calculate the unit cost of treatment and a tobit regression approach to investigate cost drivers.ResultsThe survey included 864 respondents, mainly subsistence farmers. Most respondents (87%) considered malaria to be a problem affecting their ability to perform their regular duties. Respondents preferred going to a health facility for treatment. The primary reason for not going was related to costs; 70% of respondents incurred costs for seeking health care, with a median of £3.62 (IQR: £1.73 to £6.10). The primary driver of cost was living in one of the villages that are off the main road and/or far from health facilities. 66% reported productivity loss of 5 working days on average during a malaria episode of them or their child.ConclusionsAlthough malaria prevalence is decreasing and treatment is provided free of charge, households seeking treatment are confronted with out-of-pocket expenditures and lost working days; particularly in remote villages.