Malaria Prevention and Care Seeking among Gold Miners in Guyana

"SBC [social and behaviour change] messaging may be beneficial in addressing gaps in knowledge, attitudes, and perceptions and might play an essential role in ensuring the adoption of relevant behavior such as prompt care-seeking, malaria testing, and adherence to medications..."

Miners are a priority group for malaria control in Guyana, as they are a migrant and hard-to-reach population with limited access to healthcare services. The United States Agency for International Development (USAID)-funded Breakthrough ACTION Guyana project is working in collaboration with the Guyana Ministry of Health (MoH), the Pan American Health Organization (PAHO), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to implement evidence- and theory-based social and behaviour change (SBC) interventions to support community case management of the malaria programme. Thus, this study is designed to meet the need for research on malaria-related behaviour among miners to inform the National Malaria Program (NMP) Strategy and to foster use of long-lasting insecticide-treated nets (ITNs), prompt care-seeking for malaria, and improved malaria testing uptake.

Since the pilot of the community case management initiative in April 2016, the NMP has conducted numerous volunteer trainings. Breakthrough ACTION supported the development of the training curriculum and piloted branded materials, such as flags and certificates, to increase the visibility of the community case management programme. The Breakthrough ACTION project also supported the development and distribution of counseling materials to assist testers in providing accurate information.

A cross-sectional survey was conducted among 1,685 adult gold miners living in mining camps in the hinterland Regions 1 (Barima-Waini), 7 (Cuyuni-Mazaruni), and 8 (Potaro-Siparuni). Multivariable logistic regressions explored factors associated with miners' self-report of mosquito net use, prompt care-seeking, self-medication, and testing for malaria.

Only one-third of miners used a mosquito net the night preceding the survey, despite a mosquito net distribution campaign in 2018. In addition, Guyana's health sector is a continuous distribution channel for ITNs, as they can be obtained free of charge from a health centre by miners or their camp managers. Additional efforts may be needed to ensure that this policy is widely disseminated and that miners are aware of the nearest ITN distribution channels. Tailored SBC messaging on net acquisition, use, and care could be beneficial to promoting a culture of consistent net use among miners. Notably, net use was higher among those who believed that net use was the norm in their camp (adjusted odds ratio (aOR): 3.11; 95% confidence interval (CI): 1.65, 5.88).

While no direct effect between SBC exposure and self-reported mosquito net use was seen, an indirect effect mediated by the association between SBC exposure and malaria knowledge was observed. These findings are consistent with other literature demonstrating the influence of malaria knowledge and SBC messaging on mosquito net use. Of note, no formal SBC campaign had been implemented prior to data collection, and respondents probably recalled ad-hoc messages by the MoH.

Less than half (45%) of miners had a fever in the past 12 months, among whom 36% sought care promptly, 48% tested positive for malaria, and 54% self-medicated before seeking care. Prompt care-seeking was higher among miners with high malaria knowledge (aOR: 1.44; 95% CI: 1.01, 2.05). Similarly, testing rates increased with: secondary education (aOR: 1.71; 95% CI: (1.16, 2.51); high malaria knowledge (aOR: 1.45; 95% CI: 1.02, 2.05); positive beliefs regarding malaria transmission, threat, self-diagnosis, testing and treatment; and trust in government services (aOR: 1.59; 95% CI (1.12, 2.27) and experience of a prior malaria episode (aOR: 2.62; 95% CI: 1.71, 4.00). Self-medication was lower among male miners (aOR: 0. 52; 95% CI: 0.32, 0.86).

Thus, the study found that malaria prevention and care seeking behaviours among miners are somewhat low and influenced by mosquito net usage, perceived norms, malaria knowledge, and prior episode of confirmed malaria. Study findings have implications for malaria interventions in the hinterland regions of Guyana, such as efforts to identify and address gaps in distributing mosquito nets to miners and to address miners' barriers to prompt care seeking, malaria testing, and treatment adherence For example, miners may lack appropriate awareness on the need for prompt care-seeking or malaria testing, as they perceive their symptoms to not be severe. Miners may also face other barriers to prompt care seeking and malaria testing, such as the cost of transportation, lack of time to seek testing services, and other costs in terms of lost wages when taking time off work to get tested.

The researchers conclude that, with Guyana's full rollout of the community case management initiative, malaria testing and treatment locations should be more accessible to miners in the future. Appropriate signage and billboards may be used to advertise these test locations and may be complemented with supporting print media such as treatment adherence handouts for the miners and counselling guides for the testers. The initiative may also benefit from additional SBC efforts such as community mobilisation and engagement, mass media campaigns to sensitise miners about the testing locations, and the importance of prompt care seeking and other relevant behaviour. However, these efforts need to be complemented by additional actions such as training and support to ensure that the volunteer testers have the necessary technical and communication skills, use of incentives to promote retention rates among community case management volunteer testers, and public-private partnerships between the Guyana MoH and relevant mining organisations.