Uncomplicated malaria infection and severe malaria disease case management in Sussundenga district, Mozambique

Abstract

Malaria case management through prompt diagnosis and artesunate treatment within 24 hours of symptom onset reduces malaria mortality 1. The Mozambican National Malaria Control Program (NMCP) supports universal access to care; however, malaria health disparities persist 2. Sussundenga District is a rural community in Western Mozambique, with moderate-high Plasmodium falciparum transmission 3,4. Research focused on health access and case management are traditionally research priorities in settings close to elimination. Few community-based studies on malaria prevention and treatment have occurred in Western Mozambique, although malaria prevalence for children under five was 48% higher in Manica compared to Maputo province in 2019 5. This dissertation aimed to (1) measure the community Plasmodium falciparum prevalence and symptomatic malaria health-seeking behaviors in a cross-sectional study, (2) determine the impact of ecological health access domains on severe malaria case management based on a case-control study, and (3) identify the facilitators and barriers to severe malaria case management through provider and traditional medicine practitioner interviews at the Sussundenga-Sede rural health center (RHC). In Manuscript 1, I designed surveys for a pilot cross-sectional study in Sussundenga village. The cross-sectional study occurred from December 2019 to February 2020. The community prevalence and health-seeking behaviors analysis was published in 2022. I analyzed individual and household data on malaria infection risk and factors impacting health-seeking. I identified the community Plasmodium falciparum prevalence and individual, household, and provider-level determinants of malaria treatment. I found significant gaps in individual health-seeking behaviors, while the primary site of care to receive the standard diagnosis and treatment was the Sussundenga-Sede RHC. In Manuscript 2, I designed a convergent parallel mixed-method study based at Sussundenga-Sede RHC from April 2023 to August 2024. I designed surveys, piloted with local providers, and led the completion of a case-control study for quantitative data collection. I compared severe malaria hospitalized cases and non-malarial hospitalized controls to understand ecological health access determinants. The exploratory factor analysis and generated composite variables indicated the built, social, and physical environment components impact health access. I found less built or social environment health access increased the average predicted probability for severe malaria hospitalization. In Manuscript 3, At the same time as the hospital based case-control study, I designed semi-structured interviews, piloted them with local providers, and led the qualitative data collection. I used thematic analysis, joint display tables, and data integration at multiple levels to understand severe malaria case management facilitators and barriers from diverse key decision makers. I found traditional medicine and traditional medicine practitioners could improve delayed health seeking, a common barrier from all key decision makers. In partnership with Sussundenga-Sede RHC, the Ministry of Health, and Consultores Associados de Manica, I identified multi-level determinants of malaria infection and severe disease. Future research on key determinants could improve outcomes in Sussundenga district, Mozambique.