sub-Saharan Research Articles

Renewable energy, carbon footprints, natural resources depletion and economic growth in Africa

Purpose This study aims to examine the interplay between renewable energy consumption, carbon footprints, natural resources depletion and economic growth. Design/methodology/approach It engaged 45 African countries using the generalized method of moments (GMM) approach. Data from the World Development Indicators for the period 2000–2023 are used to analyse the relationships among these variables. Findings The result indicates a positive and significant effect of greenhouse gas emissions on economic growth in all regions of Africa, except for Southern Africa. Regarding the depletion of natural resources, the authors observe a dominant negative effect on economic growth. Thus, an increase in the depletion of natural resources contributes to the reduction of economic growth in most regions of Africa, notably West Africa, East Africa and sub-Saharan Africa as a whole. Moreover, the depletion of natural resources can also have negative social impacts, such as conflicts over access to remaining resources, which can indirectly influence economic stability and growth. Originality/value This study contributes to the existing literature by providing empirical evidence of the positive effects of renewable energy consumption on carbon footprints, natural resource depletion and economic growth. By quantifying these relationships, the study offers valuable insights into the potential of renewable energy to address pressing environmental and economic challenges.

Social protection comparison across the world: a study of fiscal, structural and institutional performance discrepancies

PurposeSocial protection states the public-mandated (strategies and programmes) to address the vulnerability and risk among poor and near-poor households. Social protection must not only help people meet their basic needs but also contribute to the long-term well-being and broader societal goals of equity, social justice and empowerment. The role of social protection in achieving these goals has not been adequately documented. This paper examines the performance of the social protection mechanism from the perspective of the regional structural and institutional performance indicators. Social protection outlay dynamics are synthesized in the structural and institutional conducts.Design/methodology/approachA world regional comparability is made by considering the panel dataset for the time interval 1995–2020. In empirics, the unconditional and conditional ranks are constructed, and regression analyses are made subject to (1) the fiscal constraint of social protection, (2) structural performance indicators and (3) the institutional performance indicators of the targeted regions across the globe. The fully modified-ordinary least square (FM-OLS) method is used to construct the ranks.FindingsThe rank analysis demonstrates that the developed regions (i.e. Europe, Central Asia and North America) have relatively good welfare standards and fiscal capacity for social protection drives compared to the developing/underdeveloped regions (i.e. Sub-Saharan Africa and South Asia). The structural/institutional performance indicators have shown their significance in determining/utilizing their budget for social protection and maintaining welfare standards. Interestingly, most developed regions are relatively reluctant to maintain the structural/institutional performance for the determination/execution of the funds for social protection as compared to the developing and underdeveloped regions.Practical implicationsIn policy discourse, this research suggests that governments must make some market operations to enhance their regions’ structural and institutional performance to get better outcomes of social protection spending in the form of attractive welfare standards.Originality/valueMultiple studies have been done considering the social protection dynamics at nano, micro and macro levels, while this study considered the mega dataset across the globe to analyse the social protection dynamics in consideration of structural and institutional performances.

EPID-01. PEDIATRIC BRAIN TUMORS IN SUB-SAHARAN AFRICA:A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract OBJECTIVE brain tumors are a global problem, leading to higher cancer-related morbidity and mortality rates in children. Despite the progressive though slow advances in neuro-oncology care, research, and diagnostics in sub-Saharan Africa (SSA), the epidemiological landscape of pediatric brain tumors (PBTs) remains underestimated. This study aimed to systematically analyze the distribution of PBT types in SSA. METHODS major databases and grey literature were searched for literature on PBTs in SSA published before October 29, 2022. A proportional meta-analysis was performed. RESULTS forty-nine studies, involving 2360 children, met the inclusion criteria for review; only 20 (40.82%) were included in the quantitative analysis. South Africa and Nigeria were the countries with the most abundant data. Glioma not otherwise specified (NOS) was the common PBT in the 4 SSA regions combined. However, medulloblastoma was more commonly reported in Southern-SSA(p=0.01) than in other regions. The prevalence and the overall pooled proportion of the 3 common PBTs was estimated at 46.27% and 0.41 (95%CI 0.32–0.50, 95% prediction interval [PI] 0.11–0.79), 25.34% and 0.18 (95%CI 0.14–0.21, 95%PI 0.06–0.40), and 12.67% and 0.12 (95%CI 0.09–0.15, 95%PI 0.04–0.29) for glioma-NOS, medulloblastoma, and craniopharyngioma, respectively. Sample size moderated the estimated proportion of glioma-NOS (p = 0.02). The highest proportion of craniopharyngiomas was in Western-SSA, and medulloblastoma and glioma-NOS in Central-SSA. CONCLUSION these findings provide insight into the trends of PBT types and the proportion of the top 3 most common tumors across SSA. Although statistical conclusions are difficult due to the inconsistency in the data. We identify critical areas for policy development and collaborations that can facilitate improved outcomes in PBTs in SSA. More accurate epidemiological studies are needed to better understand the burden of the disease and the geographic variation in their distribution, and to raise awareness in their subsequent management.

The protein transition—environmental footprints of farmed fish, microalgae and chicken for food, a case study in Kenya

AbstractChallenges of land scarcity, climate change and water shortage are contributing to escalating the shortage of protein rich food in sub-Saharan Africa. In Kenya a total of 27.8% of the population was undernourished, and a total of 72.3% were categorised as moderately or severe food insecure in 2021–2022. The need to investigate alternative protein sources with less impacts on land, water and climate change, which potentially could replace, at least some of the current production of livestock as the main protein source, is getting increasingly urgent. The main aim of this study is therefore to conduct an environmental footprint analysis of favourable protein production systems in Kenya to evaluate environmental impacts on land, water, and climate. The methodological approach used in this study is referred to as environmental footprint analysis, which is applied to assess; (1) farmed fish in ponds, (2) farmed fish in solar based affordable recirculation aquaculture systems (A-RAS), (3) dried spirulina (Arthrospira Platensis), and (4) chicken from semi-intensive farms. The results show that the most promising alternatives to cattle production are dried spirulina produced in ponds, followed by fish produced in affordable recirculation systems (A-RAS) run on solar energy. Spirulina fully replacing beef production would reduce water usage with 34.7 billion m3/year, land/water surface area with 34.8 thousand km2/year, and GHG emission with 28.2 megaton CO2eq/year. For fish farmed in A-RAS, such replacement would reduce water, land and emissions with 30.7 billion m3/year, 32.0 thousand km2/ year and 23.0 megaton CO2eq/year, respectively. This study illustrates that it is possible to tackle urgent challenges of food and nutrition security for millions of people in sub-Saharan Africa and worldwide with a sustainable protein transition towards a more sustainable, inclusive production system of small-scale farmers, if making use of alternative protein sources, such as from solar based A-RAS and microalgae.

Effectiveness of military spending in reducing the intensity of armed conflict in Sub-Saharan Africa

Abstract This study empirically examines the effectiveness of military spending in reducing the intensity of armed conflict in Sub-Saharan Africa. We use a dynamic probit model, and the results show that military spending reduces the intensity of conflict. It significantly reduces low-intensity conflicts more than high-intensity conflicts. Additionally, the effectiveness of military spending depends on its level and the quality of institutions. Finally, the analysis of transmission channels shows that military spending affects conflict intensity mainly through the channel of military capabilities. We conducted several tests and robustness checks to ensure the validity of our results.

Sub-Saharan Africa: Is Monetary Policy the Miracle Cure for Financial Stability?

Sub-Saharan Africa: Is Monetary Policy the Miracle Cure for Financial Stability?

REASSURED evaluation of the Bioline HCV point-of-care testing for diagnosing hepatitis C virus infection in primary healthcare settings of Ghana: a study protocol

IntroductionHepatitis C virus (HCV) infection is a silent epidemic that needs a comprehensive and contextualised approach to manage. Access to readily available, affordable and acceptable HCV point-of-care (POC) in vitro...

Travel Time Reliability Analysis on Paratransit, case study: Substação-Muahivire route, Nampula - Mozambique

In numerous medium-sized cities in Sub-Saharan Africa, such as Nampula, the reliability of mini-bus travel time is frequently a subject of inquiry. One contributing factor to this uncertainty is the considerable number of stops made throughout the route for passenger-related purpose, including boarding and disembarking. This study utilizes data collected during off-peak periods to scrutinize the day-to-day travel time patterns of mini-buses along the route. The route has been segmented into intervals of 500 meters each, and the analysis focuses on the duration of trips at each segment. The evaluation is based on the Coefficient of Variation (CoV) of travel time, indicating the extent of dispersion in mini-bus travel time at the segment level. The results reveal that the CoVs at nearly all segments along the route are minimal, measuring less than 15%. This suggests that day-to-day variability of travel time at the segment level is negligible. However, on road segments characterized by commercial activities, the CoVs range from 15% to 22%.

A review on Biofortification of Crops: A Nutritional Strategy for Combating Malnutrition

Biofortification is an innovative agricultural approach aimed at reducing global micronutrient deficiencies, often referred to as "hidden hunger," by enhancing the nutritional quality of staple crops through breeding, genetic engineering, and agronomic practices. This strategy targets essential micronutrients such as iron, zinc, and provitamin A, particularly in regions where diets are predominantly based on nutrient-poor staple foods. Biofortified crops, such as vitamin A-enriched sweet potatoes and iron-rich beans, have demonstrated significant improvements in nutrient intake and health outcomes, including reduced anemia and enhanced child growth. Despite its promise, the adoption and widespread implementation of biofortified crops face multiple challenges, including technical constraints in breeding for nutrient stability and bioavailability, regulatory barriers for genetically modified varieties, and socio-cultural resistance due to consumer preferences and lack of awareness. Moreover, environmental factors, such as soil nutrient content and agro-ecosystem dynamics, can influence the success and sustainability of biofortification. Addressing these issues requires advancing research in nutrient bioavailability, developing more resilient crop varieties, and incorporating biofortification into broader food and nutrition policies. Scaling up biofortified crops will depend on effective community engagement, public-private partnerships, and integration into existing agricultural extension systems. Successful examples, such as the widespread adoption of orange-fleshed sweet potatoes in Sub-Saharan Africa, highlight the potential of biofortification to improve nutritional security and livelihoods when supported by targeted advocacy and policy initiatives. Thus, while challenges persist, biofortification remains a valuable, cost-effective solution to addressing micronutrient malnutrition and improving global food security, especially when implemented in tandem with other nutrition and health interventions.

Assessing socioeconomic inequality in ageing in sub-Saharan Africa: an empirical assessment of South Africa

Assessing socioeconomic inequality in ageing in sub-Saharan Africa: an empirical assessment of South Africa

Educational boundaries explain strength and variation in global fertility convergence

This paper shows that the level and timing of fertility are converging strongly over different measures of educational attainment using 65 years of data from 146 countries. Global convergence patterns are primarily driven by high-income societies, while sub-Saharan Africa is the world region that is converging most slowly, if not converging at all. Most importantly, levels of education matter heavily for explaining strength and variation in global fertility convergence, with two intersecting educational gradients suggesting: (i) stronger convergence over tertiary education followed, in turn, by secondary and primary; (ii) stronger convergence over education completed relative to education attended. Our findings provide important insights for addressing key challenges in global development and demography, and for informing policymakers as they evaluate the suitability of specific educational policies aimed at further narrowing inequalities between societies—such as supporting higher education as well as the successful completion of targeted educational cycles.

HIV Social-network intervention more effective in older populations in Kenya

US President’s Emergency Plan for HIV/AIDS has been credited with saving 25 million lives in sub-Sahara Africa and, as such, constitutes a preeminent US foreign policy achievement of the twenty-first century. However, the implementation of effective HIV/AIDS pharmacological interventions remains a challenge in rural Kenyan communities. Of particular importance are patient retention and care engagement and their interaction with age disparities that are sensitive to different socioeconomic contexts, as well as time-in-treatment. For the first time, we perform an intermediation and triple interaction intent-to-treat secondary analysis on a social network-based randomized controlled trial. We hypothesize that the temporal interactions of critical demographic features with a treatment/control indicator variable may significantly explain patient retention and that these results are intermediated by social network phenomena. We find that not only does extended time-in-treatment significantly improve primary outcomes, but the threefold interaction along with age and treatment itself is sufficiently flexible to fit the data remarkably well without unnecessary elaboration, an effect that is mediated via internalized stigma. This strongly suggests that patient retention varies by age group. Rather than deploying one-size-fits-all solutions, foreign and public policymakers should invest in research that considers how interventions might be optimized for different ages.Trial registration Clinical Trial Number. NCT02474992 (note: the main trial report was published here https://doi.org/10.1371/journal.pone.0255945.) Date of submission: June 6, 2015.

Disentangling the gender-differentiated determinants of home-based self-employment choices in Nigeria

Abstract Understanding gender disparities in home-based self-employment (HBS) and their links to homeownership and socioeconomic factors is crucial for advancing sustainable development goals (SDGs) in Sub-Saharan Africa, especially Nigeria. This study uses data from the 2010/2011, 2012/13, 2015/16, and 2018/19 waves of the Nigerian General Household Survey (GHS). It employs random effect probit regression, the LASSO method for identifying predictors, and the Blinder–Oaxaca decomposition technique to analyse gender differences in nonlinear binary outcomes. The results show that female business owners are more likely to engage in HBS compared to males, highlighting the importance of gender equality (SDG 5) and decent work (SDG 8). While male entrepreneurs are mainly driven by profit, females prioritise balancing paid and unpaid work, reflecting motivations beyond profit within heterodox economics. Significant gender-differentiated impacts are observed in relation to monthly rent, post-secondary education, dwelling space, energy, and regional locations. Notably, the presence of children significantly increases female involvement in HBS, a trend not seen among males. Marriage also influences female participation, suggesting that marital circumstances and economic benefits play a role. These findings highlight the need for policies addressing gender-specific constraints, challenging traditional gender roles, and promoting inclusive human development within the SDG framework.

Impact of Low Physical Activity on Cardiovascular Disease Across Regions and Demographic Groups: Insights from the Global Burden of Disease Study

Abstract Background Cardiovascular disease (CVD) is a leading cause of death globally, with low physical activity (LPA) as a significant modifiable risk factor. The prevalence of LPA remains high, necessitating a comprehensive assessment of its impact on CVD. Methods We applied Joinpoint regression to assess trends in deaths and Disability-Adjusted Life Years (DALYs) and employed ARIMA models to project future BMI-related burdens. Results From 1990 to 2021, CVD-related deaths due to LPA rose from 218,938 to 371,736 globally, with the most significant increases in Southeast Asia and Sub-Saharan Africa. DALYs surged from 4.47 million to 7.29 million. Although age-standardized death rates showed a slight decline in high-income countries (−2.27% EAPC), lower-income regions experienced a steady rise. YLDs grew from 344,680 to 725,181, while YLLs increased from 4.13 million to 6.57 million, with older adults (75+ years) carrying the highest burden. Conclusion The growing burden of CVD linked to LPA highlights the urgent need for interventions, particularly in low- and middle-income countries, to reduce future risks and improve public health outcomes.

Determination of the Level of von Willebrand Factor, ADAMTS13, and Ratio of ADAMTS13:von Willebrand Factor in Sickle Cell Disease Patients

Abstract Background: Sickle cell anemia (SCA) is a hypercoagulable state characterized by a significant alteration in hemostatic parameters which may predispose an increased risk of vaso-occlusive crisis (VOC). Sickle cell disease (SCD) is the most common genetic disorder in sub-Saharan Africa. Nigeria bears a high disease burden with an estimated prevalence of 1%–3% of its population being affected by the disease. The study seeks to determine the role of von Willebrand factor (VWF), ADAMTS13, and the ratio of ADAMTS13:VWF antigen in the pathogenesis of VOC. Objective: The objective of this study is to evaluate the level of VWF, ADAMTS13, and their ratio in SCD subjects in Calabar and to determine their role in the pathogenesis of VOC. Methodology: This is a comparative study carried out at the University of Calabar Teaching Hospital (UCTH), Calabar. Sixty SCA patients were evaluated in VOC and steady states as well as five parented healthy controls. VWF: Ag and ADAMTS13:Ag were evaluated using Assaypro enzyme-linked immunosorbent assay kits with Lot nos. 01751728 and 04222167R, respectively. Data were analyzed by IBM SPSS Chicago software version 21. The study was approved by the UCTH Institution Ethical Review Board. Results: The mean ages of the SCA subjects and controls were 23.5 ± 7.2 years and 26.5 ± 5.6 years, respectively (P = 0.706). There were 23 (38.3%) males in the SCA group and 21 (42.0%) females in the controls. There was no significant difference in their sex distribution (P = 0.063). The mean (standard deviation [SD]) of VWF in VOC, steady state, and controls were 2.52 ± 0.34, 1.34 ± 0.23, and 1.41 ± 0.23 IU/mL, respectively. The differences in mean were significantly higher in VOC state (P = 0.003). The mean ± SD of ADAMTS13 in VOC, steady state, and controls were 0.61 ± 0.10, 0.44 ± 0.06, and 0.62 ± 0.10 μg/L, respectively. ADAMTS13 levels did not differ significantly across the groups (P = 0.270). Similarly, there was no significant difference between ADAMTS13:VWF ratios across the groups (P = 0.318). Conclusion: VWF level is elevated in VOC state and thus may be implicated in the pathogenesis of VOC. ADAMTS13 and the ratio of ADAMTS13:VWF are not significantly affected in VOC.

Prevalence of syphilis among men serving in the militaries of Sub-Saharan Africa

ABSTRACT Background The 2030 United Nations Agenda for Sustainable Development includes targets to end sexually transmitted infections (STIs) as a major public health threat. STI prevalence data to inform strategies towards this goal are lacking in middle and low-income countries, especially among men. Methods Data from Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) conducted among militaries in Cameroon, Chad, Democratic Republic of the Congo (DRC), Ethiopia, Liberia, Malawi, Republic of the Congo (ROC), and Sierra Leone during 2013-2018 were used to estimate the prevalence of presumed active syphilis among active-duty military men. Associations of active syphilis infection with age, education, marital status, and rank for each country were assessed. Results The prevalence of active syphilis was less than 1% among men in Cameroon (2018), Ethiopia (2018), Liberia (2018), Malawi (2013), ROC (2014), and Sierra Leone (2013). In Chad (2014), 6.2% (95% CI 5.2%-7.4%; n = 121/1949) of men tested positive for active syphilis. In DRC (2014), the prevalence of active syphilis was 15.5% (95% CI 14.1%-16.9%; n = 404/2611) among men. Active syphilis was associated with older age in DRC (p < 0.01), with less education in Chad (p = 0.03) and DRC (p < 0.01), and with rank in DRC (p = 0.048). Conclusions These data help address a paucity of information on STI prevalence in sub-Saharan Africa and demonstrate the need for improved surveillance among men.

Unsupervised Classification of the Host Response Identifies Dominant Pathobiological Signatures of Sepsis in Sub-Saharan Africa

Unsupervised Classification of the Host Response Identifies Dominant Pathobiological Signatures of Sepsis in Sub-Saharan Africa

Antimicrobial stewardship in sub-Saharan African community pharmacies: a systematic review of community pharmacists’ knowledge, practice and challenges faced

Abstract Introduction The indiscriminate use of antimicrobials contributes significantly to antimicrobial resistance (AMR). The World Health Organization (WHO) recommends antimicrobial stewardship (AMS) as one of the global sustainable development interventions to tackle AMR. Implementation of AMS interventions have been documented to be successful in high-income countries 1, however, there is paucity of data regarding the implementation and effectiveness of AMS in low-income settings including sub-Sahara Africa (SSA). Community pharmacies in the SSA play a critical role in the dispensing of medicines, including antibiotics. Aim To evaluate community pharmacists' knowledge, practice, and challenges faced in relation to AMS in SSA community pharmacies. Methods The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework guided the review. We searched six electronic databases (PubMed, Web of Science, ProQuest Central, Google Scholar, African Journal Online and Wiley Online library) from January 2010 to December 2022. Reference lists of included articles were screened for additional studies. Studies published in English that described AMS interventions, antibiotic dispensing practices, community pharmacists’ knowledge and perceptions of AMS/AMR were included. Literature reviews and systematic reviews were excluded. AMS in hospital pharmacy and animal studies were also excluded. Two reviewers independently screened the abstracts and full texts according to pre-defined inclusion criteria. Disagreements were resolved through discussion. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the quality of the included studies2. Data were extracted using a standardised form in Microsoft excel and double checked for accuracy. Data were synthesised using narrative synthesis. The review protocol was registered with PROSPERO (CRD42023381320). The study did not require ethical approval because it did not involve conducting primary or secondary research involving human participants. Results The review identified 1972 articles, of which 23 studies met the inclusion criteria. Studies varied in settings, design, and data collection methods. Two broad categories were identified from the narrative synthesis. (1) Community pharmacists’ knowledge, attitude, perception, and dispensing practices (n=20). Studies reported that community pharmacists displayed an understanding of how antibiotics work. They also acknowledged threats posed by AMR. Some studies reported misconceptions on clear guidelines about the practical implementation of AMS, other studies described good adherence to antibiotic dispensing practices, including taking medication histories, assessing symptoms, advising on completion of antibiotic courses and making referrals. One study described the perception of community pharmacists of AMS as crucial for improving patient care. (2). Determinants of non-prescription antibiotic sales (n=3). The studies explored factors influencing the sale of antibiotics without prescription. Studies identified pharmacy owners’ expectations (profitability) and lack of public awareness regarding the risks of non-prescription antibiotic use as contributing factors. Limited patient access to doctors and low economic status in SSA were also cited as determinants. Conclusions Community pharmacists have knowledge of antibiotics, and they also acknowledged the importance of AMS. There were also positive dispensing practices despite existing challenges regarding implementation of AMS and sales of antibiotics without prescription. Further research should prioritize well-designed studies that evaluate the effectiveness of AMS in this setting and address the challenges identified. Heterogeneity of study methods limits the generalisability of findings.

Assessing the Efficacy of Gene-Drive Technology in Reducing Malaria Transmission in Sub-Saharan Africa: Current Progress and Future Prospects

Malaria continues to pose a significant public health challenge in Sub-Saharan Africa, necessitating innovative solutions to combat its transmission. This review examined the efficacy of gene-drive technology as a novel approach to reducing malaria transmission through genetic modifications of Anopheles mosquitoes. Utilizing a comprehensive literature review and analysis of experimental studies and pilot projects, we assessed the mechanisms of gene drives, including population suppression and replacement strategies. The findings indicated that gene-drive technology has the potential to significantly alter mosquito populations, thereby diminishing the burden of malaria. However, challenges such as ecological concerns, regulatory complexities, and public acceptance must be addressed for successful implementation. The integration of gene drives with existing malaria control measures, collaborative research efforts, and robust ethical governance is crucial for maximizing effectiveness and ensuring sustainable outcomes. Furthermore, monitoring and evaluation systems are essential for assessing the safety and efficacy of gene-drive initiatives. This review underscored the transformative potential of gene-drive technology in malaria prevention, advocating for continued dialogue among stakeholders to navigate the complexities associated with its application in Sub-Saharan Africa. Keywords: Gene-drive technology, Malaria transmission, Anopheles mosquitoes, Public health, Sub-Saharan Africa.

The Impact of Mobile Health (mHealth) Interventions on Malaria Diagnosis and Treatment Adherence among Pregnant Women: A Comprehensive Review

Malaria in pregnancy (MiP) poses a significant public health threat, particularly in sub-Saharan Africa, contributing to maternal anemia, preterm birth, low birth weight, and maternal and infant mortality. Early diagnosis and strict adherence to antimalarial treatments are essential to reduce these risks, yet access to timely care and consistent treatment adherence remain major challenges. Mobile health (mHealth) interventions, utilizing mobile technologies such as SMS reminders, diagnostic applications, and telemedicine platforms, have emerged as innovative tools to address these barriers. This comprehensive review examined the impact of mHealth interventions on malaria diagnosis and treatment adherence among pregnant women in malaria-endemic regions. Through case studies from Kenya, Nigeria, and Tanzania, we explore the effectiveness of mHealth solutions in improving maternal health outcomes by ensuring timely diagnosis and promoting adherence to treatment. Methodologically, the review drew on empirical studies, program evaluations, and case reports from peer-reviewed literature. Despite promising outcomes, challenges such as technological barriers, cultural resistance, and scalability concerns persist. Future research should focus on integrating emerging technologies like AI and machine learning to enhance mHealth’s effectiveness while prioritizing equitable access to digital health solutions. Policymakers must also prioritize the integration of mHealth into national health systems to ensure long-term sustainability. Keywords: mHealth interventions, Malaria in pregnancy (MiP), Treatment adherence, Malaria diagnosis, Sub-Saharan Africa