Understanding barriers to effective malaria diagnosis and treatment: A mixed-methods study in Uganda, Nigeria, and Ivory Coast

Malaria remains a global health challenge despite decades of intervention. We conducted a mixed-methods study using the MAPPS behavioural science framework to identify and explore behaviours relating to timely access and better adherence to antimalarials, and to offer initial ideas for interventions. Research was conducted in Uganda, Nigeria, and Ivory Coast following local ethical approval. First, qualitative face-to-face interviews were conducted with n = 18 adults with experience of malaria, n = 36 caregivers of children with experience of malaria, and n = 36 healthcare professionals (HCPs) with experience treating patients with malaria, to identify and explore the behavioural drivers and barriers to access and adherence. Cross-sectional quantitative surveys were then conducted face-to-face with respondents with experience of malaria (n = 311 adults, n = 458 caregivers, n = 532 HCPs) to quantify the incidence of the different drivers and barriers. The sample included representation from rural and urban areas, and public and private healthcare settings. This research identified key behaviours that delayed access and adherence. One-third (33%) of adults and caregivers reported delayed care-seeking from a healthcare facility when experiencing symptoms. Over a third (36%) reported not being offered a diagnostic test to confirm their diagnosis when they last sought care for malaria. 56% reported prematurely discontinuing their antimalarial medication, with 41% stating that treatment can be stopped once symptoms subside. Despite current interventions, behavioural barriers to effective malaria treatment and prevention persist. This research identified and quantified key barriers, including difficulty in identifying symptoms specific to malaria, lack of specified responsibility in testing and difficulties adhering to treatment. Communication with, and education of, patients and caregivers that emphasise the importance of seeking early care are recommended. In addition, interventions encouraging HCPs to offer, and patients or caregivers to request, appropriate testing should be explored. Finally, the use of social norming interventions to promote completion of treatment courses is also recommended.