Determinants of prompt and adequate care among presumed malaria cases in a community in eastern Rwanda: a cross sectional study.
BACKGROUND
In order to understand factors influencing fever/malaria management practices among community-based individuals, the study evaluated psychosocial, socio-demographic and environmental determinants of prompt and adequate healthcare-seeking behaviours.


METHODS
A quantitative household (HH) survey was conducted from December 2014 to February 2015 in Ruhuha sector, Bugesera district in the Eastern province of Rwanda. HHs that reported having had at least one member who experienced a fever and/or malaria episode in the previous 3 months prior to the study were included in the analysis. Healthcare-seeking behaviours associated with the last episode of illness were analysed. Socio-demographic, health facility access, long-lasting insecticidal-treated nets (LLINs), data on malaria knowledge, data and theory of planned behaviour (TPB) related variables (attitudes, subjective norms, perceived behavioural control) with regard to fever/malaria healthcare seeking, were collected. The primary outcome was prompt and adequate care defined as: (1) seeking advice or treatment at a health facility (health centre or hospital) or from a community health worker (CHW); (2) advice or treatment seeking within same/next day of symptoms onset; (3) received a laboratory diagnosis; (4) received advice or treatment; and, (5) reported completing the prescribed dose of medication. Determinants of prompt and adequate care among presumed malaria cases were evaluated using a logistic regression analysis.


RESULTS
Overall, 302 (21 %) of the 1410 interviewed HHs reported at least one member as having experienced a fever or malaria within the 3 months prior to the survey. The number of HHs (where at least one member reported fever/malaria) that reported seeking advice or treatment at a health facility (health centre or hospital) or from a CHW was 249 (82.4 %). Of those who sought advice or treatment, 87.3 % had done so on same/next day of symptoms developing, 82.8 % received a laboratory diagnosis, and more than 90 % who received treatment reported completing the prescribed dosage. Prompt and adequate care was reported from 162 of the 302 HHs (53.6 %) that experienced fever or malaria for one or more HH members. Bivariate analyses showed that head of household (HoH)-related characteristics including reported knowledge of three or more malaria symptoms, having health insurance, being able to pay for medical services, use of LLINs the night before the survey, having a positive attitude, perceiving social support, as well as a high-perceived behavioural control with regard to healthcare seeking, were all significantly associated with prompt and adequate care. In the final logistic regression model, a high-perceived behavioural control (odds ratio (OR) 5.068, p = 0.042), having a health insurance (OR 2.410, p = 0.044) and having knowledge of malaria symptoms (OR 1.654, p = 0.049) significantly predicted prompt and adequate care.


CONCLUSIONS
To promote prompt and adequate care seeking for malaria in the area, particular emphasis should be placed on community-focused strategies that promote early malaria symptom recognition, increased health insurance coverage and enhanced perceived behavioural control with regard to healthcare-seeking.
Medical Research Center, Rwanda Biomedical Center, Kigali, Rwanda. cingabire7@gmail.com.|Department of Health Promotion, Maastricht University, Maastricht, The Netherlands. cingabire7@gmail.com.
Chantal Marie
CM
Ingabire
Medical Research Center, Rwanda Biomedical Center, Kigali, Rwanda.|Academic Medical Center, Amsterdam, The Netherlands.
Fredrick
F
Kateera
Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda.|Laboratory of Entomology, Wageningen University, Wageningen, The Netherlands.
Emmanuel
E
Hakizimana
Medical Research Center, Rwanda Biomedical Center, Kigali, Rwanda.|Department of Cultural Anthropology and Development Studies, Radboud University Nijmegen, Nijmegen, The Netherlands.
Alexis
A
Rulisa
College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
Claude
C
Muvunyi
Royal Tropical Institute/Koninklijk Instituut voor de Tropen, KIT Biomedical Research, Amsterdam, Netherlands.
Petra
P
Mens
Laboratory of Entomology, Wageningen University, Wageningen, The Netherlands.
Constantianus J M
CJ
Koenraadt
College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
Leon
L
Mutesa
Academic Medical Center, Amsterdam, The Netherlands.
Michele
M
Van Vugt
Department of Health Promotion, Maastricht University, Maastricht, The Netherlands.
Bart
B
Van Den Borne
Context Factor Solutions, Nairobi, Kenya.
Jane
J
Alaii
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000962:Antimalarials / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D012432:Rwanda; D012959:Socioeconomic Factors; D055815:Young Adult
D000962:Antimalarials
Community; Health insurance; Healthcare seeking; Malaria symptoms; Rwanda; Theory of planned behaviour