Descriptive norms and care-seeking for children with fever in Africa: A multi-country study

Summary:

There is abundant evidence of the positive links between social norms and health behaviors, such as contraceptive use, antenatal care attendance, HIV care, and immunization. Prior studies have shown that people who perceive specific behaviors to be the norm in their community are more likely to adopt the behavior. However, studies that focus on the role of social norms for malaria-related behavioral outcomes are rare. Descriptive norms, or the perception that specific behaviors are the norm in one's community, are a proxy for social norms. Using cross-sectional household survey data collected in 2018-2019 from Cameroon, Cote d'Ivoire, and Sierra Leone, this study assesses the association of descriptive norms with prompt care-seeking at a health facility for febrile children under five years of age. In this study, descriptive norm is defined as the perception that at least half of the people in one's community perform the behavior. Results showed many under-five children with fever were not taken to a health facility for care within 24 hours of the onset of the fever. After controlling for socio-demographic, psychosocial, household, and community variables in a logistic regression model, descriptive norm was determined to be a statistically significant correlate of care-seeking for children with fever at a health facility within 24 hours. Social and behavior change programs may use social norm-modeling and community mobilization to position this important care-seeking behavior as a norm in the community and catalyze its uptake.

Background/Objectives:

Malaria is a major cause of morbidity and mortality among children under five years in sub-Saharan Africa. While caretakers are recommended to take children with fever to a health facility within 2 hours of the onset of fever, increasing this behavior remains a challenge in many countries. Several studies have shown that descriptive norms (the perception that specific behaviors are the norm in one's community) are associated with a greater likelihood of adopting behaviors, such as contraceptive use, antenatal care attendance, HIV care, and immunization. However, studies on the role of descriptive norms in malaria behaviors are rare.

Description Of Intervention And/or Methods/Design:

We conducted a cross-sectional Malaria Behavior Survey (MBS) in Cote d'Ivoire (2018), Cameroon (2019), and Sierra Leone (2019). The MBS is a theory-driven survey based on the ideation model. The survey was national in scope in Cote d'Ivoire, conducted in two regions in Cameroon, and in two districts in Sierra Leone. This analysis focused on children under five years of age who reportedly had fever in the two weeks before the survey. For this study, descriptive norm was defined as the perception that at least half the people in one's community perform the behavior. Using multiple logistic regression, the dependent variable was care-seeking for children at a health facility or with a community health worker within 24 hours of the onset of fever, as a first recourse, and the independent variable was the perception that at least half of those in one's community perform this behavior.

Results/Lessons Learned:

In Cote d'Ivoire, 77% of children under five with fever in the two weeks preceding the survey were taken to appropriate care at some time during their illness, however only 63% were taken within 24 hours. In Cameroon, 66%, and in Sierra Leone, 73%, were taken within 24 hours. After controlling for sociodemographic, other psychosocial, household and community variables, descriptive norm was a significant correlate of care-seeking for children with fever in a health facility. Caregivers who perceived that at least half of the people in their community performed the behavior were 2.73 times (CI:1.65-4.52; p< .001) more likely in Cote d'Ivoire, and 2.16 times (CI:1.36-3.45; p< .001) more likely in Cameroon, to promptly seek care at a health facility for a febrile child under five, compared to those who did not hold this norm. Results from Sierra Leone will be available at the time of the Summit.

Discussion/Implications For The Field:

According to the WHO, prompt diagnosis and treatment of malaria is the most effective way to prevent mild cases from developing into severe disease and death. This study demonstrates the importance of descriptive norms about prompt care-seeking in a health facility or community health worker for febrile children under five years of age. Social and behavior change programs should consider the use of social norm-modeling and community mobilization to position this important care-seeking behavior as a norm in the community and catalyze uptake of this behavior.

Abstract submitted by: 

Grace Awantang - JHU

Stella Babalola -  JHU

Kuor Kumoji - JHU

Olamide Oyenubi - JHU

Abdul Dosso - Breakthrough Action

Mieko McKay - JHU

Gabrielle Hunter - JHU