Malaria remains a major public health concern in sub-Saharan Africa, including Malawi, contributing significantly to morbidity and mortality, particularly among children under five and pregnant mothers.¹ When a child is admitted, guardians often experience intense stress, leading to high anxiety levels.² Guardians in the context of paediatric healthcare are individuals who play a vital role in caring for hospitalised children.³ These guardians may include family members, parents, legal custodians or close caregivers entrusted with the child’s well-being. In the hospital setting, these guardians often serve as the child’s primary advocates, offering emotional support and actively participating in the decision-making process regarding the child’s care.^4,5

Guardians are typically encouraged to be present with the hospitalised child throughout their hospital stay.⁶ The presence of guardians is crucial for providing comfort and reassurance to the children, assisting with daily activities and ensuring effective communication between healthcare providers and the child.⁷ However, guardians’ level of involvement and availability may vary based on individual circumstances, cultural norms and healthcare or hospital policies.⁵ Thus, the hospitalisation of a child is a challenging and emotionally intense experience for guardians who are responsible for that child’s care.

The emotional strain can progress into anxiety, which significantly impacts both caregivers’ well-being and the quality of care provided to the child.⁸ Paediatric guardians often experience heightened anxiety levels, stemming from a variety of factors, which include but are not limited to duration of hospitalisation, and type of treatment, the unfamiliar hospital environment, concerns about the child’s treatment and recovery and the emotional toll of witnessing their young loved one in distress.^9,10 The anxiety experienced by guardians can profoundly impact the quality of care provided to the child and their own well-being.¹¹

The prevalence of severe malaria among children in sub-Saharan Africa is a significant public health concern, leading to high rates of morbidity and mortality.¹ In Malawi, malaria is the leading cause of paediatric admissions, with around 40% of cases being attributed to this disease.¹² In Malawi’s healthcare system, guardians are vital for hospitalised children’s care, offering emotional support, aiding with daily tasks and working closely with healthcare staff in treatment decisions.¹³ However, there are limited data specifically addressing the prevalence and associated factors of anxiety among guardians of children admitted with severe malaria in Malawi. Therefore, this research investigated the prevalence of anxiety and associated factors among guardians of children admitted with severe malaria at Thyolo District Hospital in Malawi.

The study assessed anxiety levels among guardians of children admitted with severe malaria, focusing on demographic and clinical factors. The majority of guardians in this study reported experiencing mild anxiety, with only a small proportion experiencing moderate anxiety and minimal anxiety. Notably, no guardian reported severe anxiety. Thus, persistent mild anxiety can lead to stress-related health problems, such as emotional exhaustion and reduced physical well-being. Previous studies have shown that chronic low-level anxiety among caregivers is linked to long-term mental distress and diminished caregiving capacity.²⁰ Additionally, the hormesis theory proposes that mild anxiety may sometimes have adaptive effects, helping individuals to remain alert, focused and effective under pressure.^21,22 Thus, mild anxiety in guardians might represent a tolerable level of stress that enhances caregiving performance rather than hindering it.

This study’s finding suggests that while the emotional impact of caring for a child with severe malaria is substantial, most guardians are able to manage their anxiety at a mild level. However, the absence of severe anxiety might indicate that, despite the critical nature of the child’s condition, guardians may not reach the highest levels of anxiety. Similar studies have shown that anxiety for children with severe health conditions can lead to heightened anxiety, but severe levels of distress are less common, possibly because of the hospital and family support, which gives hope or perceived control over the child’s recovery.²³ The relatively high prevalence of mild anxiety could be attributed to the inherent stress of caregiving in a hospital setting, especially when the child’s condition is severe, but not life-threatening, to the point of overwhelming the guardian’s ability to function. However, some research suggests that even mild anxiety can accumulate and affect the caregiver’s long-term well-being.²⁴

The social demographic characteristics significantly associated with anxiety severity, as determined by chi-square tests, include several critical factors. Age emerged as a strong determinant (p < 0.001), with older individuals (50 years and above) experiencing higher levels of anxiety compared to younger groups, this is in line with a study by Canuto et al.,²⁵ suggesting that older guardians might face increased stress because of factors, such as physical challenges, less flexibility in caregiving roles or concerns about long-term health outcomes for their children.

The type of guardian also showed a significant association (p < 0.001); grandmothers demonstrated greater anxiety severity than other guardians. This is in line with existing literature, which suggests that women may experience higher levels of anxiety because of caregiving roles.²⁶ Education level was another significant factor (p < 0.001); lower educational attainment was linked to moderate anxiety. This finding suggests that lower levels of education might be associated with less access to health information,²⁷ or greater difficulty in navigating the healthcare system,²⁸ all of which could increase stress levels. Similarly, the area of residence played a role (p < 0.001), with rural residents more prone to higher anxiety levels than urban or semi-urban dwellers. Additionally, source of income exhibited a strong association (p < 0.001); farmers were more likely to report moderate anxiety compared to business owners or formally employed individuals. This could be because of various factors, including limited access to healthcare resources, transportation difficulties or a lack of immediate social support networks in rural areas.²⁹

Clinically, children presented with a range of severe malaria symptoms, including convulsions, anaemia and diarrhoea and vomiting. Despite these severe presentations, no clear patterns emerged between specific clinical manifestations and the anxiety levels of guardians. This could imply that the guardians’ anxiety is more closely related to the overall experience of caregiving in a hospital setting rather than specific symptoms. Similar findings have been observed in other studies, where the stress experienced by caregivers often stems from the uncertainty of the child’s prognosis, rather than a specific clinical event.²³ Furthermore, the duration of hospital stay was found to have a statistically significant relationship (p < 0.001) with anxiety severity. Patients staying for 2 days mostly experienced minimal to mild anxiety, while those staying for 3 days or more showed increased anxiety levels, with many moving into the moderate anxiety category. Thus, prolonged hospital stays may increase anxiety because of prolonged exposure to a stressful environment and uncertainty about recovery.³⁰

The analysis reveals a strong and statistically significant association between the number of hospital admissions and anxiety severity (p < 0.001). Patients with only one admission predominantly experienced minimal anxiety, indicating that initial hospital stays may not substantially elevate anxiety levels. However, those with two admissions showed a sharp increase in mild anxiety cases, while guardians with three or more admissions exhibited higher rates of moderate anxiety. This trend suggests that repeated hospitalisations progressively worsen anxiety levels,³¹ highlighting the need for comprehensive psychological support.

Overall, the findings of this study reveal significant associations between both socio-demographic and clinical factors and anxiety severity among patients. The study also points to the need for additional support mechanisms for guardians of children hospitalised because of severe malaria, particularly those of advanced age, women, guardians from rural areas, those with lower educational attainment, guardians who have stayed with a child for a long time in the hospital and guardians with a child admitted several times. Future studies using longitudinal or mixed methods should explore whether mild anxiety functions as a protective or harmful factor for caregivers over time to help clarify causal relationships and inform interventions for caregiver mental health. Moreover, research with larger and more diverse samples and additional qualitative methods could provide deeper insights into the complex interplay between demographic, clinical and psychological factors affecting caregivers of children with severe malaria.