Abstract
BackgroundCommunity-delivered models have been widely used to reduce the burden of malaria. This review aimed to explore different community-delivered models and their relative effectiveness in terms of coverage and malaria-metric outcomes in order to inform the design and implementation of Community Health Worker (CHW) programmes for malaria control and elimination.MethodsA systematic review of studies investigating the impact of community-delivered models on coverage and malaria-metric (parasitaemia and hyperparasitaemia, malaria case and mortality, anaemia, and fever) outcomes compared to non- community-delivered models was undertaken by searching in five databases of published papers and grey literature databases. Data were extracted from studies meeting inclusion and quality criteria (assessed using relevant tools for the study design) by two independent authors. Meta-analyses were performed where there was sufficient homogeneity in effect and stratified by community-delivered models to assess the impact of each model on coverage and malaria-metric outcomes.Results28 studies were included from 7042 records identified. The majority of studies (25/28) were performed in high transmission settings in Africa and there was heterogeneity in the type of, and interventions delivered as part of the community-delivered models. Compared to non- community-delivered models, community-delivered models increased coverage of actual bed net usage (Relative Risk (RR) = 1.64 95% CI 1.39, 1.95), intermittent preventive treatment in pregnancy (RR = 1.36 95% CI 1.29, 1.44) and appropriate and timely treatment of febrile children, and improved malaria-metric outcomes such as malaria mortality (RR = 0.58 95% CI 0.52, 0.65). However, the considerable heterogeneity was found in the impact of community-delivered models in reducing, parasitaemia and hyperparasitaemia prevalence, anaemia incidence, fever prevalence and malaria caseload. Statistical comparisons of different community-delivered models were not undertaken due to the heterogeneity of the included studies in terms of method and interventions provided.ConclusionOverall, the community-delivered model is effective in improving the coverage of malaria interventions and reducing malaria-associated mortality. The heterogeneity of the community-delivered models and their impact on malaria-metric indices suggests that evidence for context-specific solutions is required. In particular, community-delivered models for malaria elimination, integrated with services for other common primary health problems, are yet to be evaluated.
Highlights
Community-delivered models have been widely used to reduce the burden of malaria
After screening of titles and abstracts, 264 full-text articles were assessed for eligibility, and of these 28 quantified the impact of community-delivered models on coverage and malariametric indices and were included in the quantitative data synthesis (Fig. 1)
community health workers (CHW) only provided services for malaria in traditional CHW (tCHW) and Home Management of Malaria (HMM) models; additional diagnosis, treatment and referral services for other diseases from CHW were available in the Integrated Community Case Management (iCCM) model
Summary
Community-delivered models have been widely used to reduce the burden of malaria. This review aimed to explore different community-delivered models and their relative effectiveness in terms of coverage and malaria-metric outcomes in order to inform the design and implementation of Community Health Worker (CHW) programmes for malaria control and elimination. Recent reductions in malaria incidence has largely been attributed to the introduction of highly efficacious artemisinin-based combination therapy and high universal coverage of long-lasting insecticidal nets (LLIN), as well as testing (through increased availability and accessibility of rapid diagnostic tests) and targeted treatment of at-risk populations [2, 3]. One widely used model is a community-delivered model in which malaria interventions are delivered by community health workers (CHW). The use of CHW is attractive as they can be implemented with minimal training [5], they are readily available and are effective and cost-effective in resource-limited countries and several health areas [6,7,8]
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