Measuring malaria diagnosis and treatment coverage in population-based surveys: a recall validation study in Mali among caregivers of febrile children under 5 years

Abstract

Background: Nationally-representative household surveys are the standard approach to monitor access to and treatment with artemisinin-based combination therapy (ACT) among children under 5 years (U5), however these indicators are dependent on caregivers' recall of the treatment received.

Methods: A prospective case-control study was performed in Mali to validate caregivers' recall of treatment received by U5s when seeking care for fever from rural and urban public health facilities, community health workers and urban private facilities. Clinician-recorded consultation details were the gold standard. Consenting caregivers were followed-up for interview at home within 2 weeks using standard questions from Demographic and Health Surveys and Malaria Indicator Surveys.

Results: Among 1602 caregivers, sensitivity of recalling that the child received a finger/heel prick was 91.5%, with specificity 85.7%. Caregivers' recall of a positive malaria test result had sensitivity 96.2% with specificity 59.7%. Irrespective of diagnostic test result, the sensitivity and specificity of caregivers' recalling a malaria diagnosis made by the health worker were 74.3% and 74.9%, respectively. Caregivers' recall of ACT being given had sensitivity of 43.2% and specificity 90.2%, while recall that any anti-malarial was given had sensitivity 59.0% and specificity 82.7%. Correcting caregivers' response of treatment received using a combination of a visual aid with photographs of common drugs for fever, prescription documents and retained packaging changed ACT recall sensitivity and specificity to 91.5% and 71.1%, respectively.

Conclusions: These findings indicate that caregivers' responses during household surveys are valid when assessing if a child received a finger/heel prick during a consultation in the previous 2 weeks, and if the malaria test result was positive. Recall of ACT treatment received by U5s was poor when based on interview response only, but was substantially improved when incorporating visual aids, prescriptions and drug packaging review.

Keywords: Artemisinin-based combination therapy; Malaria; Population survey; Recall validation.

Fig. 1

Map of participating public urban facilities, public rural facilities, and private urban facilities. Participating community health workers were close to the two public rural facilities

Fig. 2

Participant enrolment flowchart

Fig. 3

Receiver operating characteristic (ROC) curve by site for recall of artemisinin-based combination therapy (ACT), and ROC by site type for corrected recall of ACT

Fig. 4

Inflation factor scatterplots for (i) blood test; (ii) positive blood test; (iii) malaria diagnosis (clinical or confirmed); (iv) receipt of any anti-malarial; (v) receipt of artemisinin-based combination therapy (ACT); (vi) receipt of ACT, corrected by visual aid, prescription review or retained packaging review