Understanding psychosocial determinants of malaria behaviours in low-transmission settings: a scoping review.

BACKGROUND: Recent estimates show progress toward malaria elimination is slowing in many settings, underscoring the need for tailored approaches to fight the disease. In addition to essential structural changes, human behaviour plays an important role in elimination. Engagement in malaria behaviours depends in part on psychosocial determinants such as knowledge, perceived risk, and community norms. Understanding the state of research on psychosocial determinants in low malaria transmission settings is important to augment social and behaviour change practice. This review synthesizes research on psychosocial factors and malaria behaviours in low-transmission settings. METHODS: A systematic search of peer-reviewed literature and supplemental manual search of grey literature was conducted using key terms and eligibility criteria defined a priori. Publications from 2000-2020 in the English language were identified, screened, and analysed using inductive methods to determine the relationship between the measured psychosocial factors and malaria behaviours. RESULTS: Screening of 961 publications yielded 96 for inclusion. Nineteen articles collected data among subpopulations that are at increased risk of malaria exposure in low-transmission settings. Purposive and cluster randomized sampling were common sampling approaches. Quantitative, qualitative, and mixed-methods study designs were used. Knowledge, attitudes, and perceived risk were commonly measured psychosocial factors. Perceived response-efficacy, perceived self-efficacy, and community norms were rarely measured. Results indicate positive associations between malaria knowledge and attitudes, and preventive and care-seeking behaviour. Studies generally report high rates of correct knowledge, although it is comparatively lower among studies of high-risk groups. There does not appear to be sufficient extant evidence to determine the relationship between other psychosocial variables and behaviour. CONCLUSIONS: The review highlights the need to deploy more consistent, comprehensive measures of psychosocial factors and the importance of reaching subpopulations at higher risk of transmission in low transmission contexts. Malaria-related knowledge is generally high, even in settings of low transmission. Programmes and research should work to better understand the psychosocial factors that have been positively associated with prevention and care-seeking behaviours, such as norms, perceived response efficacy, perceived self-efficacy, and interpersonal communication. These factors are not necessarily distinct from that which research has shown are important in settings of high malaria transmission. However, the importance of each factor and application to malaria behaviour change programming in low-transmission settings is an area in need of further research. Existing instruments and approaches are available to support more systematic collection of psychosocial determinants and improved sampling approaches and should be applied more widely. Finally, while human behaviour is critical, health systems strengthening, and structural interventions are essential to achieve malaria elimination goals.

Ideational factors associated with net care behaviour: a multi-country analysis.

BACKGROUND: Malaria is endemic to sub-Saharan African countries. Mass and routine distribution, promotion, and use of ITNs are critical components of malaria prevention programmes. Correct and consistent use of insecticide-treated mosquito nets (ITN) is an effective strategy for malaria prevention. To extend bed-net lifespan, the World Health Organization recommends folding or tying up ITNs when they are not in use. This study analyses factors associated with net care practices in three African countries. METHODS: Researchers collected household data nationwide in Côte d'Ivoire, from the North and Far North regions of Cameroon, and from Port Loko and Bo districts in Sierra Leone, between 2018 and 2019. The dependent variable was respondents reporting that they fold or tie up their nets. The study adjusted for selected sociodemographic, ideational (psychosocial), and household variables using multilevel models. The analysis was limited to women of reproductive age and their male spouses/partners from households with at least one ITN: 2,940 respondents in Cameroon, 6,105 in Côte d'Ivoire, and 2,730 in Sierra Leone. RESULTS: Among respondents, 50.2% in Cameroon, 52.0% in Côte d'Ivoire and 75.6% in Sierra Leone reported folding or tying up their net when it was not in use. In all three countries, the data showed significant clustering at both household and community levels, indicating the influence of factors operating at these levels on net-care behaviour. The odds of reporting the behaviour varied significantly by geographic unit in each country. Consistent use of nets was strongly correlated with net-care behaviour. Furthermore, five ideational variables were positively associated with the outcome behaviour in all three countries: positive attitude towards net care, perceived susceptibility for malaria, response-efficacy of ITNs, perceived self-efficacy for net use, and the perception that net use was a community norm. Additional significant ideational variables included positive attitudes towards net use (Cameroon and Côte d'Ivoire), perceived severity of malaria (Côte d'Ivoire), and interpersonal communication about malaria (Côte d'Ivoire). CONCLUSIONS: The study identified ideational variables associated with recommended net-care practice. Programme efforts designed to promote net-care practices and extend average lifespan of ITNs may be more effective if they emphasize positive attitudes towards net care, perceived susceptibility of malaria infection, response-efficacy of ITNs, perceived self-efficacy for net use, and promote net-care behaviour as a positive community norm.

Ideational factors associated with consistent use of insecticide-treated nets: a multi-country, multilevel analysis.

BACKGROUND: Malaria remains a major cause of morbidity and mortality in sub-Saharan Africa. Using insecticide-treated nets (ITNs) every night, year-round is critical to maximize protection against malaria. This study describes sociodemographic, psychosocial, and household factors associated with consistent ITN use in Cameroon, Côte d'Ivoire and Sierra Leone. METHODS: Cross-sectional household surveys employed similar sampling procedures, data collection tools, and methods in three countries. The survey sample was nationally representative in Côte d'Ivoire, representative of the North and Far North regions in Cameroon, and representative of Bo and Port Loko districts in Sierra Leone. Analysis used multilevel logistic regression and sociodemographic, ideational, and household independent variables among households with at least one ITN to identify correlates of consistent ITN use, defined as sleeping under an ITN every night the preceding week. FINDINGS: Consistent ITN use in Côte d'Ivoire was 65.4%, 72.6% in Cameroon, and 77.1% in Sierra Leone. While several sociodemographic and ideational variables were correlated with consistent ITN use, these varied across countries. Multilevel logistic regression results showed perceived self-efficacy to use ITNs and positive attitudes towards ITN use were variables associated with consistent use in all three countries. The perception of ITN use as a community norm was positively linked with consistent use in Cameroon and Côte d'Ivoire but was not significant in Sierra Leone. Perceived vulnerability to malaria was positively linked with consistent use in Cameroon and Sierra Leone but negatively correlated with the outcome in Côte d'Ivoire. Household net sufficiency was strongly and positively associated with consistent use in all three countries. Finally, the findings revealed strong clustering at the household and enumeration area (EA) levels, suggesting similarities in net use among respondents of the same EA and in the same household. CONCLUSIONS: There are similarities and differences in the variables associated with consistent ITN use across the three countries and several ideational variables are significant. The findings suggest that a social and behaviour change strategy based on the ideation model is relevant for increasing consistent ITN use and can inform specific strategies for each context. Finally, ensuring household net sufficiency is essential.

Malaria-related ideational factors and other correlates associated with intermittent preventive treatment among pregnant women in Madagascar.

BACKGROUND: The Malagasy Ministry of Health aimed to achieve 80% coverage of intermittent preventive treatment of malaria among pregnant women (IPTp) in targeted districts by 2015. However, IPTp coverage rates of have remained fairly static over the past few years. METHODS: During a cross-sectional household survey, mothers of children under the age of 2 years were asked about their most recent pregnancy. The primary outcome of interest was a mother receiving two or more doses of sulfadoxine-pyrimethamine (SP) (IPTp2) during their last pregnancy, at least one of which was obtained from a health provider. Multilevel analysis was used to account for community-level factors. Correlates included exposure to communication messages, the number of antenatal care (ANC) visits made by the woman, her household wealth, and other sociodemographic characteristics. RESULTS: Over one-tenth (11.7%) of women received two or more doses of SP, at least one of which was obtained during an ANC visit. Two-thirds (68.3%) of women who consulted a health provider but did not take IPTp attributed this to not being offered the medication by their health provider. The odds of a woman receiving IPTp2 varied with her knowledge, attitudes, and perceived social norms related to IPTp and ANC and exposure to malaria messages. General malaria ideation, specifically the perceived severity of and perceived susceptibility to malaria, however, was not associated with increased odds of receiving IPTp2. A large variation in the odds of receiving IPTp2 was due to community-level factors that the study did not examine. CONCLUSIONS: Health communication programmes should aim to improve IPTp/ANC-specific ideation, particularly the norms of seeking regular care during pregnancy and taking any prescribed medication. While ANC attendance is necessary, it was not sufficient to meet IPTp2 coverage. Women surveyed in Madagascar rely on health providers to prescribe SP according to national policy. At the same time, stock-outs prevent health providers from prescribing SP. The large observed community-level variation in IPTp2 coverage is likely due to supply-side factors, such as SP availability and health-provider ideation and practices.

Correlates of social behavior change communication on care-seeking behaviors for children with fever: an analysis of malaria household survey data from Liberia.

BACKGROUND: In 2010, malaria was responsible for an estimated 41% of deaths among children under the age of five years in Liberia. The same year, the Rebuilding Basic Health Services Project launched "Healthy Baby, Happy Mother," a social and behavior change communication campaign. The campaign encouraged caregivers to take children under the age of five years to a health facility as soon as children developed fever. This study investigated correlates of two case management outcomes: care-seeking for children under five with fever during the past two weeks and administration of an artemisinin-based combination therapy (ACT) the same or next day as fever onset. METHODS: Data from a 2014 cross-sectional household survey from four counties was used to investigate correlates of two case management outcomes. Using multilevel analysis, the association between these outcomes and a caregiver's recall of the campaign, her sociodemographic characteristics, and unmeasured characteristics of the community she lived in was investigated. RESULTS: Caregivers living in Grand Kru County were less likely (OR = 0.21, 95% CI 0.073, 0.632) to take a child to a health facility than those in Bong County. Caregiver recall of the campaign was positively associated with the odds that a child received an ACT promptly (OR 3.62, 95% CI 1.398-9.372), but not with the odds of a caregiver taking a child in their care to a health facility. While unmeasured community-level factors accounted for 19.0% of the variation in the odds that a caregiver's child was brought to a health facility, they did not play a role in the odds of prompt ACT treatment. CONCLUSIONS: Recalling the "Healthy Mother, Happy Baby" campaign was positively associated with the odds that children received ACT promptly, even in the absence of other malaria prevention and treatment messaging. While caregiver exposure was not associated with care-seeking during the two weeks before interview, prompt care-seeking likely preceded prompt receipt of ACT since most ACT came from health facilities. Unmeasured community-level factors, such as distance from the health facility, may play a role in determining the odds that a caregiver takes a child to a health facility.

Associations between ideational variables and bed net use in Madagascar, Mali, and Nigeria.

BACKGROUND: The use of insecticide-treated bed nets (ITNs) is crucial to the prevention, control, and elimination of malaria. Using household surveys conducted in 2014-2015 by the Health Communication Capacity Collaborative project in Madagascar, Mali, and Nigeria, we compared a model of psychosocial influence, called Ideation, to examine how malaria-related variables influence individual and household bed net use in each of these countries. Evaluations of non-malaria programs have confirmed the value of the ideational approach, but it is infrequently used to guide malaria interventions. The study objective was to examine how well this model could identify potentially effective malaria prevention approaches in different contexts. METHODS: Sampling and survey designs were similar across countries. A multi-stage random sampling process selected female caregivers with at least one child under 5 years of age for interviews. Additional data were collected from household heads about bed net use and other characteristics of household members. The caregiver survey measured psychosocial variables that were subjected to bivariate and multivariate analysis to identify significant ideational variables related to bed net use. RESULTS: In all three countries, children and adolescents over five were less likely to sleep under a net compared to children under five (OR = 0.441 in Madagascar, 0.332 in Mali, 0.502 in Nigeria). Adults were less likely to sleep under a net compared to children under five in Mali (OR = 0.374) and Nigeria (OR = 0.448), but not Madagascar. In all countries, the odds of bed net use were lower in larger compared to smaller households (OR = 0.452 in Madagascar and OR = 0.529 in Nigeria for households with 5 or 6 members compared to those with less than 5; and OR = 0.831 in Mali for larger compared to smaller households). Of 14 common ideational variables examined in this study, six were significant predictors in Madagascar (all positive), three in Mali (all positive), and two in Nigeria (both negative). CONCLUSION: This research suggests that the systematic use of this model to identify relevant ideational variables in a particular setting can guide the development of communication strategies and messaging, thereby improving the effectiveness of malaria prevention and control.

Associations between malaria-related ideational factors and care-seeking behavior for fever among children under five in Mali, Nigeria, and Madagascar.

Malaria remains one of the leading causes of morbidity and mortality among children under five years old in many low- and middle-income countries. In this study, we examined how malaria-related ideational factors may influence care-seeking behavior among female caregivers of children under five with fever. Data came from population-based surveys conducted in 2014-2015 by U.S. Agency for International Development-funded surveys in Madagascar, Mali, and Nigeria. The outcome of interest was whether a child under five with fever within two weeks prior to the survey was brought to a formal health facility for care. Results show a wide variation in care-seeking practices for children under five with fever across countries. Seeking care for febrile children under five in the formal health sector is far from a norm in the study countries. Important ideational factors associated with care-seeking behavior included caregivers' perceived social norms regarding treatment of fever among children under five in Nigeria and Madagascar, and caregiver's knowledge of the cause of malaria in Mali. Findings indicate that messages aimed to increase malaria-related knowledge should be tailored to the specific country, and that interventions designed to influence social norms about care-seeking are likely to result in increased care-seeking behavior for fever in children under five.

Correlates of Intra-Household ITN Use in Liberia: A Multilevel Analysis of Household Survey Data.

Malaria is a major cause of morbidity and mortality in Liberia. At the same time, insecticide-treated net (ITN) ownership and use remain low. Access is a key determinant of ITN use but it is not the only one; prior studies have identified factors that affect the use of ITNs in households with at least one ITN. These factors operate at the individual, household, and community levels. However, studies have generally not assessed the psychosocial or ideational determinants of ITN use. Using 2014 household survey data, this manuscript examines the socio-demographic, ideational, household, and community factors associated with household member use of ITNs in Liberia. Multilevel modeling was used to assess fixed effects at the individual, household, and community levels, and random effects at the household and cluster levels. The data showed significant residual clustering at the household level, indicating that there were unmeasured factors operating at this level that are associated with ITN use. The association of age with ITN use was moderated by sex such that men, older children, and teenagers were less likely to sleep under an ITN compared to women and children under five years old. Female caregivers' perceived severity of malaria, perceived self-efficacy to detect a complicated case of malaria, and exposure to the "Take Cover" communication campaign were positively associated with ITN use by members of her household. The association with household size was negative, while the relationship with the number of ITNs was positive. Programs should seek to achieve universal coverage (that is, one ITN for every two household members) and promote the notion that everyone needs to sleep under an ITN every night. Programs should also seek to strengthen perceived severity of malaria and educate intended audience groups on the signs of malaria complications. Given the significance of residual clustering at the household level, interventions that engage men as heads of household and key decision-makers are relevant.