Background

Malaria is a preventable and curable yet life-threatening transmitted through the bite of mosquitoes infected with the protozoan parasite Plasmodium [1]. Of the five parasite species that infect humans, Plasmodium falciparum and Plasmodium vivax poses the greatest threat [2,3]. The World Health Organization (WHO), reported that malaria caused 249 million cases globally in 2022, with 93.6% of the cases occurred in the WHO African Region. That same year, malaria accounted for 608,000 deaths, and 94.5% of which were from the WHO African Region where under five children accounted for 78.1% of the deaths [4].

In 2022, Tanzania, an East African country alone accounted for 4% of global malaria deaths, making it one of the four African countries responsible for just over half (52%) of all malaria deaths [4]. The entire country is considered at risk of malaria although the prevalence varies geographically with highest rate at 23% and the lowest at < 1% [5]. Plasmodium falciparum is responsible for 96% of all malaria infection in the country while P. vivax and P. ovale account for the remaining 4% [6]. To date, malaria remains a significant public health issue in the country, particularly among vulnerable populations such as children and pregnant women. It contributes to more than 10% of deaths among under five children with a prevalence rate of 7% in this vulnerable cohort making them disproportionately affected by the disease [7]. This vulnerability is primarily attributable to the absence of acquired maternal immunity and the immaturity of their immune systems, leaving them susceptible to the severe forms of the disease [8].

Most malaria deaths occur at home without appropriate medical care, and when care is sought, it is often too late [9]. When prevention fails, effective malaria case management with first-line Artemisinin Combination Therapy (ACT) is crucial for preventing complications and mortality in children under five [10]. The WHO emphasizes that early diagnosis and prompt treatment, within 24 hours of symptom onset, are essential for successful malaria control [9,11–13]. To support this, in April 2012, WHO’s Global Malaria Control Program launched the “3 Ts” initiative (Test, Treat, and Track) aimed at enhancing malaria testing, ensuring drug administration aligns with test results, and improving case reporting. This initiative mandates that malaria cases be tested and treated based on results from Rapid Diagnostic Tests (RDTs) or microscopy, hence promoting responsible health-seeking behavior when individuals suspect they have malaria symptoms [14].

Malaria’s early symptoms can resemble those of other febrile conditions, so individuals experiencing fever should seek care at a suitable healthcare facility to rule out malaria or other potential causes [14]. However, in sub-Saharan Africa, high malaria-related mortality rates particularly among under five suggest that only a small proportion of malaria cases receive timely treatment [13]. The risk of death from severe malaria is highest within the first 24 hours, but many patients in endemic settings seem to live far from healthcare facilities, making timely treatment difficult [15]. A systematic review in Kenya reported that only 5% of fever cases received prompt treatment with an anti-malarial drug [16]. Another study conducted in children of 15 years and under in Equatorial Guinea documented that close to half of the children (46.7%) received treatment at least 24 hours after the onset of the symptoms with the median delay in seeking care being 2.8 days within a range of 2–15 days [9]. These findings highlight substantial delays in seeking treatment for malaria symptoms among children in several African countries and emphasize the need for targeted studies and interventions to improve timely access to malaria care.

Despite Tanzania’s high malaria prevalence and mortality rates, studies on prompt malaria care-seeking behavior in the country remain scarce. A study conducted in Dodoma, the capital city of Tanzania showed that only 55.4% of under five children received care within 24 hours of fever onset [11]. However, to the best of our knowledge, no extensive, nationwide studies have been conducted to examine malaria care-seeking behavior among caregivers of febrile children. This gap highlights a critical need for research to better understand regional differences in care-seeking behavior and their implications for malaria outcomes.

This present study is significant as early diagnosis and treatment of malaria are essential for reducing its severe health impacts on young populations [17]. Understanding the determinants of prompt diagnosis and timely treatment of malaria in young children can help inform policy makers and health promoters to reduce malaria-related morbidity and mortality in the country. Thus, the study has the potential to shape malaria policy and prevention strategies in Tanzania, contributing to the achievement of the Sustainable Development Goal (SDG) 3 and Target 3.3. which aims to ensure healthy lives and well-being for all ages by ending epidemics like AIDS, tuberculosis, and malaria [17]. This study, therefore, aims to investigate the prevalence and determinants of prompt malaria care-seeking behavior in this demographic within Tanzania.

Methods

Study variables

Outcome variable.

The outcome variable for this study was defined as “whether children with fever whose advice or treatment (care) were sought same or next day”. The outcome variable was defined as binary variable, with value of 1 “yes” implying those children with fever whose care was sought on the same or next day, otherwise, the value was defined as 0 “no”.

Independent variables.

The selection of the variables included in this study was based on literature [14,18,19]. The variables were based on child’s characteristics (child’s age and sex), maternal characteristics (mother’s age, education, marital status and parity), household characteristics (residence, wealth index, sex of head of household, household size, bed-net usage and zone) as well as health system characteristics (time to nearest health facility and health insurance). All variables were used as categorical with different defined levels (see Table 1) in exception of household size which was used as continuous variable.

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Table 1. Social demographic characteristics of the respondents (N = 1050).

https://doi.org/10.1371/journal.pone.0319913.t001

Results

Modified multivariable Poisson regression model with robust estimator

Based on the findings, after controlling for confounders, a mothers’ age, level of education, childs’ sex, and household size were found to be significant factors associated with prompt care-seeking for children at a 95% confidence level. Caregivers aged 25–34 years had a 36% higher prevalence of seeking care for their child on the same day or the next day compared to caregivers under 25 years (95% CI: 1.37 (1.05, 1.78)). Caregivers aged 35–49 years had a 61% higher prevalence of timely care-seeking for their under-five children compared to caregivers under 25 years (95% CI: 1.61 (1.16, 2.23)).

Having a female child was associated with an 18% less prevalences of a mother seeking prompt malaria care compared to having a male child (95% CI: 0.82 (0.68, 0.98)). Caregivers with primary education had 50% higher prevalence of seeking timely malaria care for their children compared to caregivers with no formal education (95% CI: 1.50 (1.12, 2.02)). Additionally, caregivers with secondary or higher education had 36% higher prevalence of seeking malaria prompt care as compared to caregivers with no formal education, although this result was not statistically significant at the 95% confidence interval (95% CI: 1.36 (0.94, 1.95)). As one member increase in household size, the prevalence of a mother seeking malaria prompt care for her child will increase by 3%. (95% CI: 1.03 (1.01, 1.05)).

The usage of bed nets and access to health insurance were associated with a 4% (95% CI: 1.04 (0.85,1.27)) and 7% (95% CI: 1.07 (0.76, 1.51)) higher prevalences of caregivers seeking prompt malaria care for their children, respectively, compared to those without bed nets or health insurance. Caregivers with two to four children had 17% less prevalences of seeking malaria prompt care compared to caregivers with one child (95% CI: 0.83 (0.62, 1.10)). Caregivers with five or more children had 27% less prevalences of seeking prompt malaria care compared to caregivers with one child (95% CI: 0.73 (0.50, 1.05)). But, bed-net usage as well as health insurance and parity were not significant for this study (Table 2).

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Table 2. Factors associated with malaria prompt care seeking behavior on same or next day.

https://doi.org/10.1371/journal.pone.0319913.t002

Discussion

This study investigated the prevalence of prompt malaria care-seeking behavior among children under five in Tanzania and its associated factors. The findings revealed that 43.2% of children received prompt malaria care either on the same day or the following day, while the remaining children did not receive timely care. This is concerning, given malaria’s status as a leading cause of fever among children in Tanzania, where timely care is essential for reducing the disease’s morbidity and mortality. The observed prevalence is lower than the 100% rate reported in a previous study using data from the 2010 Tanzania Demographic and Health Survey (DHS) [22], and is comparable to the 44.6% reported in a cross-sectional study conducted in Dodoma, Tanzania [11]. Our prevalence rate is also similar to the 46.3% reported in a study conducted in neighbouring country, Malawi [23], indicating that these trends may be regionally consistent. Importantly, our study utilized the most recent DHS data (2022), which reflects the latest trends and changes in health-seeking behavior. This dataset benefits from updated methodologies, and broader coverage, offering a more accurate representation of the current situation. Additionally, the COVID-19 pandemic may have influenced health-seeking behavior, potentially altering caregivers’ concerns about visiting healthcare facilities or shifting health priorities.

Findings from this study show that both childhood and caregivers’ factors, are associated with the prevalence of prompt malaria care seeking behavior among febrile children under-five years in Tanzania. In terms of child-related factors, sex was significantly associated with the prevalence of prompt malaria care seeking behavior among febrile children. Consistent with other studies [15,24], this study found that being classified as male or female significantly influenced a mother’s likelihood of seeking prompt malaria care. Specifically, having a female child was associated with an 18.3% less likelihood of a mother seeking malaria care on the same or next day compared to having a male child. This is probably because male children may be perceived as future breadwinners or bearers of the family name, leading to quicker and more decisive healthcare actions when they fall ill [25,26].

Also, parents are more willing to invest in healthcare for male children, perceiving them as having greater economic value in future than female children [27]. This underscores the need for targeted public health campaigns that directly address cultural biases favoring male children. These campaigns should focus on raising awareness about the importance of providing equal access to timely healthcare for both male and female children. Additionally, there is a critical need for gender-sensitive education that challenges existing gender norms and highlights that prompt medical care is equally crucial for all children, regardless of sex. By emphasizing the equal value of both male and female children in the context of healthcare, such initiatives can help reduce gender-based disparities and improve health outcomes for all children. Concerning caregivers’ factors, age and education level were significantly associated with prompt malaria care seeking behavior for under five children in Tanzania. Our study found that children whose caregivers were 25 years and older were more likely to seek prompt malaria care compared to those with younger caregivers. This may be due to the greater experience and maturity of older caregivers, leading to better health literacy and understanding of the importance of timely treatment. Additionally, older caregivers may have more stable socioeconomic conditions and better access to resources, facilitating quicker access to healthcare services. The same results have been in Malawi and Uganda [23,28]

Another interesting finding was that caregivers that had attained primary and secondary education were more likely to seek prompt healthcare for their febrile children than those with no formal educational background. Although the association is not significant for individuals with secondary education, these findings underscore the critical role of maternal education in malaria prevention and treatment. This is consistent with results reported in previous studies [29–31] indicating that women with secondary or higher levels of education were more likely to use healthcare systems than those with no formal education. Plausible reasons may include the point that education enhances health literacy, equipping caregivers with knowledge about the importance of timely medical intervention [32]. Educated caregivers are more aware of the symptoms of serious illnesses like malaria and the potential risks of delayed treatment [33]. Additionally, education often correlates with improved socioeconomic status and access to resources, such as healthcare services and transportation, which further facilitates prompt care-seeking behavior [34]. This finding underscores the importance of maternal knowledge and awareness in health-seeking behavior. Educated caregivers might have better understanding and recognition of malaria symptoms and the urgency required in seeking treatment, emphasizing the need for creating educational interventions aimed at caregivers with no formal education.

Household size was another significant factor. An increase in the number of household members was associated with an increase in the likelihood of prompt malaria care-seeking. Larger households may benefit from shared responsibilities, allowing caregivers to seek timely care for their children. This finding suggests that community and family support systems are vital in facilitating prompt healthcare access. This is contrary to the result in the studies done in Ethiopia and Rwanda [31,35] which highlighted that households with many family members were less likely to seek healthcare for the sick child when compared to those having fewer household members. This could be due to the high workload, responsibilities due to large family size and financial constraints which prevented them from visiting appropriate healthcare facilities for their illnesses. This finding underscores the importance of social and familial support in health behaviors. Public health strategies should harness the strengths of larger households, such as shared responsibilities and collective knowledge, to promote timely healthcare-seeking. Nevertheless, the conflicting findings highlight the need for further research to better understand the factors influencing healthcare-seeking behavior in different family sizes. Investigating the underlying reasons for these discrepancies, including potential variations in cultural, socioeconomic, and systemic factors, will provide more nuanced insights. This additional research can help identify specific barriers and facilitators to healthcare access, enabling the development of targeted interventions and policies that address the unique needs of diverse populations.

Unexpectedly, while the use of bed nets and access to health insurance suggested a 3% and 8% increase in healthcare-seeking behavior, respectively, these factors were not statistically significant in our study. Additionally, variables such as the child’s age, parity, place of residence, marital status, wealth index, sex of the household head, and the distance to the nearest healthcare facility did not show significant associations in our context, contrary to findings in other settings. Potential reasons for these discrepancies could include regional differences in healthcare infrastructure, socioeconomic conditions, or cultural practices that influence health-seeking behaviors. The implications of these findings underscore the need for localized research to understand the unique determinants of healthcare utilization in different settings, which could inform more effective and context-specific health policies and interventions [9,11,15,36,37].

Together, these findings indicate the need for tailored policy, research and practice to address regional differences in malaria care-seeking behaviors among caregivers of under five children in Tanzania. The key findings from the analysis reveal several significant insights with important implications for policy, research, and practice. Specifically, the study highlights that female children and caregivers aged 25-34 and 35 + are associated with higher rates of prompt care-seeking, while education level and household size also influence healthcare behaviors. These findings suggest that policies should prioritize educational initiatives for caregivers and consider age-specific health interventions. Additionally, despite some factors like bed net use and health insurance showing potential associations with care-seeking, they were not statistically significant, indicating a need for more nuanced research into the effectiveness of these interventions in different contexts. For practice, healthcare providers in Tanzania should tailor their approaches to account for demographic and socioeconomic factors that influence care-seeking behavior, ensuring that interventions are relevant and accessible to all segments of the population. Further research is needed to explore these relationships in greater depth and to identify other potential barriers or facilitators to healthcare access, which can inform more targeted and effective health policies and programs.

Conclusions

The study’s findings indicate that only 43.2%of caregivers sought healthcare for their febrile children within 24 hours of symptom onset, revealing a significant delay in accessing prompt malaria treatment. Key determinants influencing timely healthcare-seeking included the caregiver’s age, education level, socioeconomic status, and household size. This delay is particularly troubling given the high prevalence of malaria and the urgent need for timely intervention to mitigate related morbidity and mortality. We recommend educational programs to challenge gender biases and support young caregivers, promoting better health-seeking behavior and malaria awareness. We also recommend shared responsibilities in larger households to foster prompt health seeking.

Acknowledgments

The authors acknowledge the Measure DHS for providing us with the data set.