"...the ideational approach sheds light on how multiple factors often interact and have simultaneous influence over healthcare decisions. This allows for more nuanced and sophisticated communication strategies that are more likely to be effective for particular behaviours, audiences, and localized contexts."

In Guyana, little information is available on psychosocial factors influencing malaria care-seeking and treatment among miners, who are a priority population for malaria elimination. But in general, research has demonstrated the influence of knowledge, perceptions, decision-making patterns, and interpersonal relationships on health care-seeking. The conceptual framework of the study draws from the ideation model, a predictive model of behaviour change that focuses on the multiple, inter-related psychosocial variables that commonly influence individual behaviour. This study explores the relationship between gold miners' malaria-related ideation and the adoption of malaria care-seeking and treatment behaviours, including prompt care-seeking, malaria testing, and self-medication. Study findings will be used to inform the design of relevant social and behaviour change (SBC) interventions among this high-risk population as well as the ongoing Community Case Management Initiative (CCM), which is a volunteer testing programme implemented by the National Malaria Programme (NMP) to support greater access to malaria services by miners.

The ideation model recognises that most behavioural decisions are driven by multiple psychosocial factors, often simultaneously. The ideation model has three components, each of which comprises several elements: (i) cognitive elements, which include variables such as attitudes, beliefs, values, perceived risk, subjective norms, and self‐image; (ii) emotional elements, which include emotional response, empathy, and self‐efficacy variables; and (iii) social elements, including social support and influence, spousal communication, and personal advocacy variables. These variables function like risk-factors for disease, but in a positive way: The more of these ideational variables that apply to a person, the more likely that individual is to adopt the behaviour. These ideational variables are also influenced by communication, whether through social interaction, mass media, or interpersonal communication. The factors work both individually and synergistically to influence health outcomes.

Data are from a cross-sectional quantitative survey of 1,685 adult miners between the ages of 18-59 years who live in mining camps in Regions 1, 7, and 8 of Guyana. This survey was part of a baseline assessment for the United States Agency for International Development (USAID)-funded Breakthrough ACTION project in collaboration with the NMP of the Guyana Ministry of Health (MoH). The analysis focused on miners who reported an episode of fever in the past year (n = 745). Malaria care-seeking and treatment ideation was defined as a composite additive score consisting of the following variables: general malaria knowledge, perceived severity, perceived susceptibility, beliefs, perceived self-efficacy, perceived norms, interpersonal communication, and perceived response efficacy. Multivariable logistic regressions explored the relationship between ideation on care-seeking/treatment behaviours, controlling for confounding variables.

Most miners with a recent episode of fever had perceived risk (92%), self-efficacy (67%), susceptibility (53%), and high malaria knowledge (53%). On the other hand, only about one-fifth of miners either perceived social norms that support treatment adherence (21%) or engaged in interpersonal communication regarding malaria prevention (20%).

Overall, miners' care-seeking/treatment ideation score ranged from 0 to 8, with a mean of 4.1. Ideation scores were associated with higher odds of care-seeking for fever (adjusted odds ratio (aOR): 1.19; 95% confidence interval (CI) 1.04-1.36), getting tested for malaria (aOR: 1.22; 95% CI 1.07-1.38), and lower odds of self-medication (aOR: 0.87; 95% CI 0.77-0.99). While certain individual ideational factors were more strongly associated with some outcomes than others, the cumulative ideation score was associated with greater adjusted marginal odds for each of the outcome behaviours. This finding suggests programmatic value in communication strategies that emphasise multiple factors, rather than single factors, especially among miners with lower ideation to begin with - for instance, younger miners, those with less education, and those with less access to mobile phones and other media.

According to this study, care-seeking messages should focus on increasing miners' knowledge of malaria transmission and symptoms, as well as the conditions in the mining camps that make a miner susceptible to the disease. In contrast, messages about malaria testing should combine information about malaria knowledge with encouragement of positive beliefs about malaria testing and volunteer testers, evidence about the effectiveness of testing as a protective strategy, reminders of how quick and easy it is to get a malaria test somewhere nearby, and the fact that one's peers will support you if you get tested when you have a fever. This analysis can inform both media messaging as well as outreach efforts in remote regions, where mobile health workers can be guided with talking points about multiple factors to emphasise when discussing particular behaviours with their clients.

The study findings are being used in the implementation of SBC interventions for miners. As detailed at Related Summaries, below, the NMP and Breakthrough ACTION Guyana project are implementing a mass media campaign informed by human-centred design to address miners' ideation related to care-seeking and treatment and to increase demand for malaria related services. The campaign spans a variety of channels, including radio, television, print materials, and social media. Central to the campaign is the use of a fictional miner's experience and messages to increase risk perception, malaria knowledge, prompt care-seeking, and treatment adherence, as well as other influential persons in the mining community speaking out on the need for prompt and proper care-seeking for malaria. The mass media campaign is complemented by other interventions to ensure the delivery of high quality of testing and treatment services as the CCM initiative is being scaled up by the NMP.

The Breakthrough ACTION Guyana project is complementing the NMP efforts by branding malaria testing and treatment locations with flags to increase the visibility of the CCM programme. The volunteer testers are given certificates after training to promote their buy-in and validate them within their communities. The volunteer testers are also given job aids such as rapid counselling cards and a treatment pocket guide to improve the quality and accuracy of the service provided. Treatment adherence handouts are given to malaria positive clients that illustrate how the treatment works to encourage treatment adherence. An endline survey of miners is to be conducted to assess the impact of these interventions on miners' behaviours and malaria outcomes.

Per the researchers, this study also has implications for efforts to eliminate malaria across the Guiana Shield, including Suriname, Brazil, and Venezuela, which have been also impeded by gold mining, high rates of self-medication due to inaccessible health facilities, and the importation of malaria cases.