Ideational factors associated with appropriate care-seeking for fever among caregivers of children under five years of age: a multi-country analysis in sub-Saharan Africa

(2025) 24:291 Casella et al. Malaria Journal https://doi.org/10.1186/s12936-025-05534-z Malaria Journal Open Access RESEARCH Ideational factors associated with appropriate care‑seeking for fever among caregivers of children under five years of age: a multi‑country analysis in sub‑Saharan Africa Albert Casella1*, Michael Bride1, Gabrielle C. Hunter1, Michael Toso1, Grace N. Awantang2, Alain K. Koffi3, Jayme Hughes4, Thérèse Bleu5, Bolanle Olapeju6, Abdul Dosso7, Florence Mpata8, Eric Sompwe Mukomena9,10 and Stella Babalola1 Abstract Background With an estimated 247 million cases and 619,000 deaths reported worldwide in 2021, malaria remains a major cause of morbidity and mortality. The World Health Organization (WHO) Africa region accounts for most cases and deaths. As children under the age of five are especially vulnerable to malaria, seeking care for a febrile child within 24 hours of the start of a fever at a facility or community health worker (i.e., appropriate care-seeking) is a foundational behaviour for reducing risk of malaria mortality. However, faced with a wide range of possible approaches and content that can be employed by social and behaviour change (SBC) programmes to improve care-seeking for fever, it can be challenging for decision-makers to focus efforts and resources on the most promising strategies. This study examines factors influencing appropriate care-seeking for fever among caregivers of children under five years of age in Côte d’Ivoire, the Democratic Republic of Congo, and Benin with the aim of informing SBC programmes on ways to focus efforts and resources. Methods Data for this analysis was collected via Malaria Behaviour Surveys (MBS) conducted in Côte d’Ivoire, the Democratic Republic of Congo, and Benin. Participants in each country were selected using a multi-stage cluster random sampling approach to capture representative data at the sub-national level. Behavioural, demographic, and ideational data pertaining to malaria were collected using similar data collection tools in each country. Analyses were limited to female caregivers of children under five with fever in the past 14 days (723 in Côte d’Ivoire, 974 in the Democratic Republic of Congo, and 460 in Benin). Multivariate logistic regression models assessed the association between appropriate care-seeking for febrile children under five and ideational and sociodemographic independent variables. Results Varying sociodemographic and ideational factors were significant in each country. The percentage of caregivers reporting appropriate care-seeking for children was 62% in Côte d’Ivoire, 41% in the Democratic Republic of Congo, and 53% in Benin. Child age, household poverty, geographic zone of residence, and exposure to malaria *Correspondence: Albert Casella Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Casella et al. Malaria Journal Page 2 of 15 (2025) 24:291 messages were significantly associated with appropriate care-seeking in one or two of the countries. Correct knowledge about optimal timing to seek care for a febrile child was positively associated with the behaviour in all three countries, as was interpersonal discussion about malaria. Other variables, including attitudes, perceived self-efficacy, the perception that the behaviour is normative among parents in the community, and the perception that health workers charge parents for malaria services, yielded a significant association in at least one country. Conclusions Several variables were associated with appropriate care-seeking in the three countries, suggesting that specific factors can be leveraged for SBC programmes seeking to increase appropriate care-seeking. First, programmes that expand exposure to malaria-related messages are likely to reach people in need. The modalities needed to reach the needed population vary by country. Health communication emphasizing the need for prompt action after a child’s fever onset (i.e. the same or next day) and that care should be sought directly at a health facility will address prevalent current knowledge gaps. Further, programmes may benefit to promote interpersonal discussion about malaria between spouses, families, and friends, particularly if the discussion is centred around the wellbeing of children in the community. Given the strong trends observed in these factors across three countries, they may also be relevant to other countries in francophone Africa. Finally, country-specific strategic directions are also recommended for factors that were significant in only one country. Keywords Malaria, Care-seeking, Ideation, Fever, Children under-five, Côte d’Ivoire, Democratic Republic of the Congo, DRC, Benin Background Malaria care‑seeking behaviour in sub‑Saharan Africa In 2022, there were 249 million malaria cases and 619,000 malaria deaths across 85 endemic countries and areas. The World Health Organization (WHO) Africa region accounts for 94% of global cases and 95% of deaths [1]. While malaria deaths in this region have been reduced by 44% over the past two decades, progress has stalled among some sub-Saharan African countries. Malaria deaths among children under five years of age reflect this global trend. The proportion of total malaria deaths occurring among children under five has been reduced from 87% in 2000 to 77% in 2020, though they remain the most vulnerable to the impacts of infection [2]. Appropriate care-seeking for fever (defined as seeking care within the same or next day at a health facility or through a trained health worker) is an important behaviour for reducing malaria mortality. Population surveys across sub-Saharan Africa indicate modest improvements in care-seeking for fever among children underfive years of age (from 65% in 2005 to 67% in 2019), with most caregivers seeking care from public health facilities [1]. Surveys such as Demographic and Health Survey (DHS) and Malaria Indicator S (...truncated)