Health seeking behaviour for acute respiratory illness among adults in rural Malawi: implication to emerging respiratory infections surveillance

Abstract Background: Emerging respiratory infections threaten the global population, especially as we are experiencing the COVID-19 Pandemic. Such novel respiratory infections usually target the young adult population. In Malawi, the national surveillance system is in place, but no evidence to know if we can capture their incidents at the community level. Little is known about adults' acute respiratory illness (ARI) health-seeking behaviour in Malawi and Africa, as it is usually the presented symptom when these novel respiratory pathogens attack young adults. Our study was to fill the knowledge gap to understand the adult's health-seeking behaviour and pathway to guide future surveillance system enhancement. Methods: This was a qualitative study in which we applied a focus ethnographical methodology with a grounded approach to collect data from formal health service providers from the facility and community level, general adults from the community and traditional healers to triangulate the study aims. The study was conducted in a rural area of northern Malawi during 2016-2018. We used Colvin's model as the initial framework for data analysis to understand the adult ARI health-seeking behaviour process and the roles of different social actors along the path. Results: After the analysis, we considered that self-cognition and constant evaluation of the severity is a constant process determining an adult's decision to access formal services. Homemade remedies, especially herbal medicines, were widely used by adults as the immediate response to the illness. Among the other two processes, surrounding social actors played a role when negotiating support for accessing formal biomedical service, while the "middle layer" was the main process patient used prior to accessing services at facilities. The ARI incidents and mortality surveillance gaps exist at community and facility levels. Conclusions: Health surveillance assistants could fulfil their community surveillance function by expanding their care and treatment capacity. Furthermore, future surveillance system enhancement shall consider engaging drug vendors and traditional healers inclusively to become an essential event-based surveillance data source from the community. The ongoing development of the digital health systems in the country shall also provide its readiness for emerging respiratory infection surveillance.