This is the first nationally representative study from Myanmar reporting care-seeking behaviour for fever and ITN utilization among the vulnerable under-five population. The study had some interesting findings.
This study finding highlighted that only less than one-fifth of under-five children slept under an ITN the night prior to the survey. This is probably due to poor ownership of ITNs which is also reported in previous studies from Myanmar [12, 15]. This calls for mass distribution of ITNs with emphasis on households with under five children to improve ownership of ITNs. Household mapping which is done before distribution of ITNs should be meticulously planned especially while doing a head count in households with under five children.
Previous studies in African countries have reported higher utilization of ITNs among children ranging from 42 to 51% [7, 23]. Studies from Myanmar have also reported higher ITN utilization of 45–50% among the migrant population and the Regional Artemisinin Resistance Initiative areas of Myanmar, probably due to the increased focus of the programme through heightened routine activities and increased external funding in these high risk areas [24, 25]. Reasons for poor ITN utilization among caregivers of under-five children in this study need to be explored through qualitative research.
This study demonstrated higher utilization rates for ITN among rural children than their urban counterparts similar to previous studies [26]. This was contrary to what was found in a meta-analysis of 13 surveys, which included five Demographic Health Surveys for African countries, where children in urban households were found to be more likely to use nets than children in rural households [27]. One possible reason for this could be the low incidence of malaria in urban areas such as Yangon and Mandalay which are moving towards malaria elimination. This leads to low perceived threat of mosquito bite and probably also explains the poor ITN utilization in malaria elimination regions. However, the exact reasons require an in-depth qualitative exploration.
Low ITN use has been reported in the delta and hilly regions. This is concerning for the programme as these are high malaria transmission regions. The reasons are beyond the scope of this study, warranting further qualitative studies.
Among the caregivers of under-five children with a fever, only two-third sought care. This figure is much lower than the 100% defined by the Myanmar National Malaria Control Programme [28]. This finding is alarming, given that malaria is a major cause of fever in children in Myanmar and prompt care-seeking is necessary to reduce morbidity and mortality. It suggests the need for intensified social and behaviour change communication strategies to improve care-seeking efforts. The results are similar to what was reported in previous studies from Senegal and Mozambique, in which around one-third of children with fever did not receive any treatment or medical advice [29, 30].
However, previous studies from Myanmar have reported higher proportion (~ 80%) of children with fever receiving care, possibly because these studies were conducted in specific groups of populations such as the migrants, ethnic minority groups and malaria endemic rural areas which are high priority areas for the national malaria programme and receives maximum attention and resource allocation. Also, the definition used to define care-seeking varied across studies [21, 31, 32].
Respondents residing in the hilly areas have reported poor care-seeking probably due to the difficult terrain, thus creating access barriers to seeking care. The role of village level volunteers is crucial in these areas to provide doorstep decentralized services.
This study showed poor care-seeking among caregivers of under-five children belonging to the lowest socio-economic status. This has been reported by several studies from low-middle income countries [33,34,35]. These findings are also consistent with studies focusing on other childhood illnesses, such as diarrhoea and ARI in similar settings [36, 37]. Concerns about payment for consultation remain a barrier to seeking health care and achieving better health outcomes for the poor.
The proportion of children with fever getting tested for malaria was dismally low with only 3%. Similar concerns were also raised in previous studies among migrants and the general population in Myanmar which reported lower uptake of malaria testing (12–24%) [18, 32]. Several patient (self-medication, not giving due importance to fever, transportation difficulty, uninformed about malaria testing by VHV) and provider (lack of test kits, testing only seriously ill patients) related factors were identified in a qualitative study done previously to explain poor uptake of malaria testing [32]. These factors need to be tackled as part of a comprehensive strategy to improve the knowledge and practice of caregivers related to malaria, especially the need for testing within 24 h of fever. Malaria being a major killer among under-fives, appropriate management of fever among children should be a national programme priority to achieve zero malaria deaths.
The major strengths of the study were that the data were obtained from a large nationally representative survey covering all the states/regions of Myanmar; the survey followed a standard DHS methodology; the response rate was high; missing values were minimum; and the subject is an identified national and global research priority. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the reporting of observational studies.
The study had few limitations. The study did not explore reasons for poor health-seeking behaviour in case of fever and poor utilization of ITNs which require qualitative studies in future. Also, the study did not explore other personal and behavioural factors such as knowledge, attitude, beliefs and perception regarding the role of ITN and health care-seeking which are known to influence behaviours. The responses were self-reported which could be influenced by social desirability bias, although, wherever possible, observation of self-reported ITNs and ITNs mounted over the sleeping area was done during the interview.