Towards improved uptake of malaria chemoprophylaxis among West African travellers: identification of behavioural determinants

Abstract

Background: Malaria is a potentially lethal illness for which preventive measures are not optimally used among all travellers. Travellers visiting friends and relatives in their country of origin (VFRs) are known to use chemoprophylaxis less consistently compared to tourist travellers. In this study, factors explaining the low use of chemoprophylaxis were pursued to contribute to improving uptake of preventive measures among VFRs.

Methods: Following in-depth interviews with Ghanaians living in Amsterdam, a questionnaire was developed to assess which behavioural determinants were related to taking preventive measures. The questionnaire was administered at gates of departing flights from Schiphol International Airport, Amsterdam (the Netherlands) to Kotoka International Airport, Accra (Ghana).

Results: In total, 154 questionnaires were eligible for analysis. Chemoprophylaxis had been started by 83 (53.9%) and bought by 93 (60.4%) travellers. Pre-travel advice had been obtained by 104 (67.5%) travellers. Those who attended the pre-travel clinic and those who incorrectly thought they had been vaccinated against malaria were more likely to use preventive measures. Young-, business- and long-term travellers, those who had experienced malaria, and those who thought curing malaria was easier than taking preventive tablets were less likely to use preventive measures.

Conclusion: Almost half of the VFRs travelling to West Africa had not started chemoprophylaxis; therefore, there is room for improvement. Risk reduction strategies could aim at improving attendance to travel clinics and focus on young-, business and long term travellers and VFRs who have experienced malaria during consultation. Risk reduction strategies should focus on improving self-efficacy and conceptions of response efficacy, including social environment to aim at creating the positive social context needed.

Figure 1

Behavioural model for obtaining pre-travel advice, buying anti-malarial tablets and starting anti-malarial tablets. Experience includes experience of disease, of the use of chemoprophylaxis and previous travel. Personality variables include demographics and travel details. Social includes social support and model behaviour. Determinants were structured based on three behavioural models. The Theory of Planned Behaviour (TPB) includes external variables (demographics, personality traits and environmental influences), attitudes (whether people regard a given behaviour positively or negatively), subjective norms (what the social environment thinks about the behaviour and how it acts) and perceived behaviour control (PBC) (expected personal performance of behaviour) as determinants. These determinants influence intention to perform behaviour, and intention predicts whether behaviour is performed. In the Health Belief Model (HBM), motivation to perform behaviour, perceived health threat and perceived reduction of this threat determine whether a given behaviour is performed. The Protection Motivation Theory (PMT) includes perceived severity of a threatening event, vulnerability of individuals (the chance that the health threat will occur), efficacy of recommended preventive behaviour and self-efficacy (defined as PBC in the TPB). This theory includes previous behaviour as an additional determinant.