Health-seeking behavior and diagnostic gaps for febrile illness in malaria-risk areas of Mesoamerica and the Dominican Republic: a multi-country cross-sectional study

Background Timely diagnosis and treatment of malaria are essential for interrupting transmission and preventing mortality, and passive case detection depends on febrile individuals both seeking care and being tested for malaria. This study describes the health-seeking cascade for febrile illness, from care-seeking to malaria testing, among individuals aged 15 years or older with fever in the preceding two weeks in malaria-risk areas of Belize, Colombia, Costa Rica, the Dominican Republic, Guatemala, Honduras, Nicaragua, Panama, and El Salvador, and explores factors associated with care-seeking. Methods This descriptive study analyzed a multi-country cross-sectional household survey with linked health facility surveys. Data were collected between September 2019 and March 2020 in communities within the catchment areas of public health facilities; 964 individuals aged 15 years or older who reported fever in the preceding two weeks were included. Survey-weighted proportions were estimated for each cascade step, and bivariate mixed-effects logistic regression models were used to explore associations between sociodemographic, behavioral, and health system factors and care-seeking. Results Care-seeking for fever ranged from 42.8% in Honduras to 74.8% in Panama, and most individuals who sought care attended health facilities. However, malaria testing was very low: the proportion of febrile individuals tested for malaria ranged from 0.4% in Costa Rica and 0.7% in El Salvador to 29.4% in Panama, and in every country most of those who sought healthcare were not tested. Self-treatment was the most frequently reported reason for not seeking care. In exploratory bivariate analyses, secondary or higher education (OR=1.78, 95% CI 1.02–3.10), high wealth (OR=1.70, 95% CI 1.05–2.76), having heard of malaria (OR=2.56, 95% CI 1.71–3.83), and the presence of a voluntary collaborator in the community (OR=2.16, 95% CI 1.32–3.55) were associated with higher odds of care-seeking. Conclusions Despite relatively high care-seeking, malaria testing among febrile individuals remains critically low, representing missed opportunities for case detection and a major bottleneck for malaria elimination. Testing every febrile person who reaches a health facility or community provider in malaria-risk areas, together with strategies that address self-treatment and low perceived risk, should be a priority for elimination programs in the region.