Behavioural and socio-economic risk factors and pathways associated with malaria in children in Ghana: A mediation analysis

Background: Malaria remains a major threat to public health and a leading cause of morbidity and mortality especially among children under 5 years old in Ghana. In 2019, approximately 40.000 children in Ghana died from malaria. While a relationship between sustainable development and malaria control has long been recognised, the implementation of structural interventions is restricted by a limited understanding of the causal pathways between poverty and malaria. Objectives: This study contributes to addressing this gap by investigating (i) relevant socio-economic factors at the household-level, (ii) constructing a Ghana-specific household wealth index (HWI), and (iii) exploring potential behavioural and socio-economic factors mediating the effect of socio-economic positioning (SEP) on reported malaria fever events in children under the age of 5 in Ghana. Methods: Data analyses are based on Ghana Malaria Indicator Survey (GMIS) household and individual-level data from 2019 provided by the DHS program. Principal Component Analysis (PCA) was conducted to develop an asset-based HWI. Mediation analysis was used to explore the potential mediators (i.e. treatment-seeking, bed net use, educational attainment, housing conditions) and to assess the relative contribution of their effect. Results: A higher educational attainment (EA) of mothers and living in improved housing jointly mediate 18 % of the association between SEP and malaria fever events, which is in line with previous evidence on housing improvements. The EA and visiting formal prenatal care provider mediate 20 % of the total effect, also when having a poor socio-economic position. No strong mediation between SEP and malaria fever events was found by EA and use of LLINs in this study (7.5 %). Conclusion: The findings suggest that current biomedical and behavioural malaria control efforts could be strengthened by investments at the structural levels, such as increased (female) education, targeted improvements in housing and integration of informal health care. Future research should focus on further investigating the complex pathways between poverty and malaria, which can inform more holistic, multisectoral strategies for sustainable malaria control