title: Treatment-seeking rates in malaria endemic countries.
abstract: BACKGROUND
  The proportion of individuals who seek treatment for fever is an important quantity in understanding access to and use of health systems, as well as for interpreting data on disease incidence from routine surveillance systems. For many malaria endemic countries (MECs), treatment-seeking information is available from national household surveys. The aim of this paper was to assemble sub-national estimates of treatment-seeking behaviours and to predict national treatment-seeking measures for all MECs lacking household survey data.
  
  
  METHODS
  Data on treatment seeking for fever were obtained from Demographic and Health Surveys, Malaria Indicator Surveys and Multiple Cluster Indicator Surveys for every MEC and year that data were available. National-level social, economic and health-related variables were gathered from the World Bank as putative covariates of treatment-seeking rates. A generalized additive mixed model (GAMM) was used to estimate treatment-seeking behaviours for countries where survey data were unavailable. Two separate models were developed to predict the proportion of fever cases that would seek treatment at (1) a public health facility or (2) from any kind of treatment provider.
  
  
  RESULTS
  Treatment-seeking data were available for 74 MECs and modelled for the remaining 24. GAMMs found that the percentage of pregnant women receiving prenatal care, vaccination rates, education level, government health expenditure, and GDP growth were important predictors for both categories of treatment-seeking outcomes. Treatment-seeking rates, which varied both within and among regions, revealed that public facilities were not always the primary facility type used.
  
  
  CONCLUSIONS
  Estimates of treatment-seeking rates show how health services are utilized and help correct reported malaria case numbers to obtain more accurate measures of disease burden. The assembled and modelled data demonstrated that while treatment-seeking rates have overall increased over time, access remains low in some malaria endemic regions and utilization of government services is in some areas limited.
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. katherine.battle@zoo.ox.ac.uk.
authors.forename: Katherine E
authors.initials: KE
authors.lastname: Battle
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. donal.bisanzio@zoo.ox.ac.uk.
authors.forename: Donal
authors.initials: D
authors.lastname: Bisanzio
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. harry.gibson@zoo.ox.ac.uk.
authors.forename: Harry S
authors.initials: HS
authors.lastname: Gibson
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. samir.bhatt@zoo.ox.ac.uk.
authors.forename: Samir
authors.initials: S
authors.lastname: Bhatt
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. ewan.cameron@zoo.ox.ac.uk.
authors.forename: Ewan
authors.initials: E
authors.lastname: Cameron
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. daniel.weiss@zoo.ox.ac.uk.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Weiss
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. bonniemappin@gmail.com.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Mappin
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. ursula.dalrymple@zoo.ox.ac.uk.
authors.forename: Ursula
authors.initials: U
authors.lastname: Dalrymple
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. rosalind.howes@zoo.ox.ac.uk.
authors.forename: Rosalind E
authors.initials: RE
authors.lastname: Howes
authors.affiliation: Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford, UK. sihay@uw.edu.|Fogarty International Center, National Institutes of Health, Bethesda, MD, USA. sihay@uw.edu.|Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. sihay@uw.edu.
authors.forename: Simon I
authors.initials: SI
authors.lastname: Hay
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, UK. peter.gething@zoo.ox.ac.uk.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
mesh_terms: D000962:Antimalarials / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D006296:Health Services / Q000706:statistics & numerical data*; D006306:Health Surveys; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D008962:Models, Theoretical; D011247:Pregnancy
chemical_list: D000962:Antimalarials