Malaria community case management usage and quality of malaria care in a moderate Plasmodium falciparum burden region of Chadiza District, Zambia

Abstract

Background: Malaria community case management (CCM) can improve timely access to healthcare, and CCM programmes in sub-Saharan Africa are expanding from serving children under 5 years (CU5) only to all ages. This report characterizes malaria case management in the setting of an age-expanded CCM programme in Chadiza District, Zambia.

Methods: Thirty-three households in each of 73 eligible communities were randomly selected to participate in a household survey preceding a trial of proactive CCM (NCT04839900). All household members were asked about fever in the prior two weeks and received a malaria rapid diagnostic test (RDT); those reporting fever were asked about healthcare received. Weighted population estimates were calculated and mixed effects regression was used to assess factors associated with malaria care seeking.

Results: Among 11,030 (98.6%) participants with RDT results (2,357 households), parasite prevalence was 19.1% by RDT; school-aged children (SAC, 5-14 years) had the highest prevalence (28.8%). Prior fever was reported by 12.4% of CU5, 7.5% of SAC, and 7.2% of individuals ≥ 15 years. Among those with prior fever, 34.0% of CU5, 56.0% of SAC, and 22.6% of individuals ≥ 15 years had a positive survey RDT and 73.7% of CU5, 66.5% of SAC, and 56.3% of individuals ≥ 15 years reported seeking treatment; 76.7% across all ages visited a CHW as part of care. Nearly 90% (87.8%) of people who visited a CHW reported a blood test compared with 73.5% seen only at a health facility and/or pharmacy (p < 0.001). Reported malaria treatment was similar by provider, and 85.9% of those with a reported positive malaria test reported getting malaria treatment; 66.9% of the subset with prior fever and a positive survey RDT reported malaria treatment. Age under 5 years, monthly or more frequent CHW home visits, and greater wealth were associated with increased odds of receiving healthcare.

Conclusions: Chadiza District had high CHW coverage among individuals who sought care for fever. Further interventions are needed to increase the proportion of febrile individuals who receive healthcare. Strategies to decrease barriers to healthcare, such as CHW home visits, particularly targeting those of all ages in lower wealth strata, could maximize the benefits of CHW programmes.

Keywords: Plasmodium falciparum prevalence; Community health workers; Healthcare seeking; Malaria; Malaria case management.

Fig. 1

Locations and parasite prevalence of survey clusters, April—May, 2021. Clusters are outlined in black and households surveyed are blue points. Parasite prevalence by RDT indicated by shading of the cluster and health facilities in the district are noted by the cross marker

Fig. 2

A Parasite prevalence and 2-week prevalence of fever with positive survey RDT. The red bars represent the population adjusted parasite prevalence by age with the vertical lines representing the upper bound of the 95% confidence interval and the percentage shown on the left axis. The dark blue line is the 2-week prevalence of fever with positive survey RDT by age group (right axis). The light blue line is 2-week prevalence of fever with positive survey RDT plus reported receipt of artemisinin-based combination therapy (ACT) in the prior 2 weeks (right axis). B Proportion of household members with a positive study RDT (red), 2-week prevalence of fever with a positive survey RDT (dark blue) and 2-week prevalence of fever with positive survey RDT and reported receipt of an ACT (light blue). The bars indicate population adjusted prevalence by age group and the black lines indicate the 95% confidence interval

Fig. 3

Malaria-care cascades for study participants who reported fever in the prior two weeks, stratified by age group and survey RDT result (A–F). The number of study participants contributing to each diagram are listed in the titles. All percentages are the median population adjusted percentages. Responses of “not known” were excluded in the graphic as they make up less than 2% of the responses. Sought treatment indicates a report of receiving healthcare in the formal sector, though it could have been delivered at the home by CHWs or outside the home. Pos Positive, neg negative

Fig. 4

Reported formal healthcare sources accessed for febrile illness among those who sought healthcare, stratified by whether a community health worker (CHW) was reported as accessed. The bars indicate the population adjusted median percentage, the black lines encompass the 95% confidence interval of the estimate. In the purple bars, a CHW was accessed in addition to the other providers listed. In the yellow bars, a CHW was not reported as accessed

Fig. 5

Malaria-care cascade for study participants who reported fever in the prior 2 weeks and sought care, stratified by survey RDT result and whether a CHW was accessed as part of the healthcare received (A–D). The number of study participants contributing to each diagram are listed in the titles. All percentages are the median population adjusted percentage. Percentages do not add up to 100% as survey responses of ‘not known’ were excluded from the flow diagram for clarity but included for calculation of the adjusted percentages