Interpersonal communication, cultural norms, and community perceptions associated with care-seeking for fever among under-fives in Magoé district, Mozambique

Background: Malaria is endemic throughout Mozambique, contributing significantly to the country’s burden of disease. Prompt and effective treatment for fevers in children can limit the mortality and morbidity impacts of the disease but many children in the country are not taken for formal care. Using an ideational model of behavior, this study assesses the magnitude of the relationships between potential drivers of care-seeking - interpersonal communication, malaria messaging, and ideational factors – and actual care-seeking behaviors for under-five children with fever in Magoé district, Mozambique. Methods: Using data come from a 2019 household malaria survey for a random sample of women of reproductive age, multilevel random effects logistic regression models are estimated to test for associations between care-seeking behaviors and hypothesized behavioral determinants, including interpersonal communication (IPC), malaria messaging, ideational factors (e.g., norms, attitudes, beliefs, risk perceptions), and community characteristics. Results: Overall, 18.5% of children under age five (N=300) were reported to have fever in the previous 2 weeks and, of these, 68.5% were taken to a formal sector health care provider. Multivariate models highlight significant roles for interpersonal communication; care-seeking was highest among mothers who spoke only with friends/community members about malaria (94.0%, p<.001), followed by those who spoke only with their husband (78.6%, p=.015), relative to 63.3% who spoke with no one. Care-seeking decisions made by a child’s grandmother were associated with a 25.0 percentage point (p=0.001) greater likelihood of seeking care relative to decisions made by the mother alone. Exposure to any malaria messaging was also positively associated with care-seeking (90.5% versus 62.7%, p<.001). In contrast, among all individual- and community-level ideational factors, only perceptions of self-efficacy to seek care are related to care-seeking behaviors. Conclusions: These results suggest that social and behavior change interventions that focus on encouraging families and community members to talk about malaria and the need to promptly seek treatment for fevers in children may be particularly effective at increasing this behavior in this and similar settings. Such messaging and IPC should consider grandmothers as a target audience, as they appear to be perceived as highly influential in care-seeking decision-making in this community.