{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T11:48:08Z","timestamp":1791805688043,"version":"4.3.4"},"reference-count":33,"publisher":"BMJ","issue":"5","license":[{"start":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T00:00:00Z","timestamp":1779926400000},"content-version":"unspecified","delay-in-days":27,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000200","name":"United States Agency for International Development","doi-asserted-by":"publisher","award":["OAA-A-17-00017"],"award-info":[{"award-number":["OAA-A-17-00017"]}],"id":[{"id":"10.13039\/100000200","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,5,15]]},"published-print":{"date-parts":[[2026,5]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To identify psychosocial and structural barriers to prompt malaria care-seeking in Malawi by applying the Three Delays Model (delay 1: deciding to seek care; delay 2: reaching a facility; delay 3: receiving quality care).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>cross-sectional study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Nationally representative data collected from Malawi communities between 25 May 2021 and 1 July 2021.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>913 female caregivers who reported a child with fever in the past 2\u2009weeks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary outcome measures<\/jats:title>\n                    <jats:p>Prompt care-seeking for fever (same or next day) from a qualified health provider.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Prompt care-seeking was primarily associated with delay 1 (adjusted OR (aOR) 0.58, 95%\u2009CI 0.43 to 0.78)\u2009and psychosocial (aOR 0.59; 95%\u2009CI 0.44 to 0.79) factors. Significant factors included incorrect knowledge of malaria symptoms, cause and diagnosis (aOR 0.71: 95%\u2009CI 0.53 to 0.97), negative attitudes towards care-seeking (aOR 0.58; 95%\u2009CI 0.41 to 0.82), incorrect knowledge of when and where to seek care (aOR 0.19: 95%\u2009CI 0.07 to 0.50)\u2009and far distance from a health facility (aOR 0.67, 95%\u2009CI 0.49 to 0.93).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Despite the availability of free malaria services, significant bottlenecks remain in the initial decision-making phase. To reduce malaria mortality, national programmes should prioritise social and behaviour change interventions that move beyond general awareness to target specific care-seeking attitudes and intra-household decision-making dynamics.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-115859","type":"journal-article","created":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T15:25:34Z","timestamp":1779981934000},"page":"e115859","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Three delays of malaria care-seeking in Malawi: a cross-sectional study"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2958-2708","authenticated-orcid":false,"given":"Bolanle","family":"Olapeju","sequence":"first","affiliation":[{"name":"Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Bride","sequence":"additional","affiliation":[{"name":"Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tyson","family":"Volkmann","sequence":"additional","affiliation":[{"name":"U.S. President\u2019s Malaria Initiative, US Centers for Disease Control and Prevention Research Centers, Lilongwe, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shelby","family":"Cash","sequence":"additional","affiliation":[{"name":"U.S. President\u2019s Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention Research Centers, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edson","family":"Dembo","sequence":"additional","affiliation":[{"name":"U.S. President\u2019s Malaria Initiative, USAID, Lilongwe, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Kayange","sequence":"additional","affiliation":[{"name":"National Malaria Control Program, Government of Malawi Ministry of Health, Lilongwe, Central Region, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Austin","family":"Gumbo","sequence":"additional","affiliation":[{"name":"National Malaria Control Program, Government of Malawi Ministry of Health, Lilongwe, Central Region, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taonga","family":"Mafuleka","sequence":"additional","affiliation":[{"name":"National Malaria Control Program, Government of Malawi Ministry of Health, Lilongwe, Central Region, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Boyle","sequence":"additional","affiliation":[{"name":"Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alfred","family":"Mang\u2019ando","sequence":"additional","affiliation":[{"name":"Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nyanyiwe Masingi","family":"Mbeye","sequence":"additional","affiliation":[{"name":"Evidence Informed Decision Making Centre, Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences School Global and Public Health, Blantyre, Southern Region, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chime","family":"Mukwakwa","sequence":"additional","affiliation":[{"name":"Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,5,28]]},"reference":[{"key":"2026052808251947000_16.5.e115859.1","unstructured":"World Health Organization . Global technical strategy for malaria 2016-2030. 2021. 9241564997."},{"key":"2026052808251947000_16.5.e115859.2","unstructured":"Government of Malawi Ministry of Health . National malaria strategic plan (2023-2030). 2023."},{"key":"2026052808251947000_16.5.e115859.3","doi-asserted-by":"crossref","DOI":"10.1186\/s13561-020-00271-2","article-title":"Determinants of healthcare seeking and out-of-pocket expenditures in a \u201cfree\u201d healthcare system: evidence from rural Malawi","volume":"10","author":"Nakovics","year":"2020","journal-title":"Health Econ Rev"},{"key":"2026052808251947000_16.5.e115859.4","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2020-002766","article-title":"Allocating resources to support universal health coverage: policy processes and implementation in Malawi","volume":"5","author":"Twea","year":"2020","journal-title":"BMJ Glob Health"},{"key":"2026052808251947000_16.5.e115859.5","unstructured":"Malawi Ministry of Health . 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Determinants of healthcare seeking for childhood illnesses among caregivers of under-five children in urban slums in Malawi: a population-based cross-sectional study. 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Communication and behavior change: The role of ideation. Center for Communications Programs, Bloomberg School of Public Health. 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