Presented at the November 2013 ASTMH Conference.

1. Background
Timeliness of Malaria Treatment in Children Under Five Years of Age in sub-Saharan Africa:
A Multicountry Analysis of National-scale Household Survey Data
Methods
Timely access to effective treatment with artemisinin combination therapies (ACTs) is fundamental to preventing the development of severe malaria,
particularly among children in sub-Saharan Africa. The World Health Organization (WHO) recommends initiating treatment promptly after the onset of
fever and parasitological confirmation. However, there are limited national-level studies that investigate time delays between the onset of fever and
the initiation of treatment. This study assesses the extent to which children under 5 years of age have access to prompt and effective treatment in 12
of the 15 priority countries outlined by the United States President’s Malaria Initiative. It also identifies predictors of prompt and effective treatment
and describes profiles of children who were treated according to WHO recommendations.
Results
Data Sources (Figure 1)
• Demographic and Health
Survey (DHS)
• Malaria Indicator Survey (MIS)
• Anemia & Parasite Prevalence
Survey (A&PS)
In each country, the most recent
survey with data on time to
treatment was used. Surveys are
from 2006 to 2011, with most in
2010 and 2011. Countries are
from West, Central and East
Africa.
Conclusions
Overall, the proportions of children who received prompt antimalarial treatment are high among children
whose mother has at least a secondary education, those living in urban areas, and those belonging to the
highest (4th and 5th) wealth quintiles. The CHAID model revealed that maternal education and household
wealth quintile are key predictors of prompt treatment with effective antimalarial medicine. In the effort to
ensure universal access to effective treatment, particular attention must be paid to these groups to ensure
they are effectively covered. This will require an effective monitoring and evaluation system capable of
detecting disparities early. The authors recommend keeping these results in mind for future routine system
strengthening activities.
Acknowledgments
This study was made possible by support from the U.S. Agency for International
Development (USAID) under the terms of Cooperative Agreement GPO-A-00-03-00003-
00. The opinions expressed are those of the authors and do not necessarily reflect the
views of USAID, or the United States Government.
Overall, country of residence is the best predictor of access to prompt
treatment with an ACT (p-value<0.001). The CHAID model classified
countries into 6 nodes.
Table 2: Best Predictors of Prompt Access to ACT
• Group 1 has a gain index of 115% and represents 33%
of the sample. This group accounts for 38% of all
children who received prompt and effective treatment.
• Group 2 has a gain index of 98.5%, represents 53% of
the sample. This group accounts for 62% of all children
who received prompt and effective treatment.
• Group 3 has a gain index of 71%, represents 14% of the
sample. This group accounts for 10% of all children who
received prompt and effective treatment.
Figure 3: CHAID Model Output Table 3: Gain Index
Jui A. Shah1, Jacques B. Emina2, Yazoume Ye1
1MEASURE Evaluation/ICF International, 2INDEPTH-Network and University of Kinshasa
Node Node description
Node Gain %
24h5 Index6
N1 %2 N3 %4
Group 1 2,059 32.5 1,504 37.5 73.0 115.3
14 Mozambique, Zanzibar, mother ages 20–29 199 3.1 171 4.3 85.9 135.6
15
Mozambique, Zanzibar, mother ages 15–19 or 30–
49
209 3.3 157 3.9 75.1 118.5
16 Uganda urban residents 334 5.3 240 6.0 71.9 113.4
4 Malawi, Rwanda, Senegal, Tanzania 1,317 20.8 936 23.3 71.1 112.1
Group 2 3,366 53.1 2,102 52.3 62.4 98.5
11 Liberia lowest (1st quintile) and highest (5th quintile) 303 4.8 205 5.1 67.7 106.8
17 Uganda rural residents 1,515 23.9 1,000 24.9 66.0 104.2
7 Angola, Ghana, Zambia secondary and + 358 5.6 220 5.5 61.5 97.0
13 Liberia lower (2nd quintile) and 4th quintile 445 7.0 263 6.5 59.1 93.3
9 Kenya, Madagascar secondary and + 111 1.8 63 1.6 56.8 89.6
18
Angola, Ghana, Zambia no education and primary;
wealth highest (5th quintile), higher (4th quintile),
lowest (1st) quintile
634 10.0 351 8.7 55.4 87.4
Group 3 912 14.4 410 10.2 45.0 70.9
12 Liberia middle wealth quintile (3rd quintile) 147 2.3 71 1.8 48.3 76.2
19
Angola, Ghana, Zambia no education and primary;
wealth middle (3rd quintile) and low (2nd quintile)
388 6.1 176 4.4 45.4 71.6
10
Kenya/ Madagascar– mothers with non education
or primary
377 5.9 163 4.1 43.2 68.2
Total 6,337 100 4,016 100 63.4 -
Notes:1 Number of cases per node (demographic size in the sample); 2 Demographic size in percentage =
(.1/Σ.1)*100; 3 Number of children who received prompt treatment; 4 Demographic size among children who
received prompt treatment in percentage = (.3/Σ.3)*100;5 Proportion of children who received prompt
treatment = (.3/Σ.1)*100; 6 Node Index = ((.3/Σ3)/ (.1/Σ.1))*100.
Statistical Analysis
• Restricted to children who received any antimalarial
• Chi-square Automatic Interaction Detector (CHAID)
using Stata 12
o Outcome: Treatment with ACT within 24 hours
o Predictors: Country of residence, maternal
education, wealth index, maternal age, duration
of ACT implementation
o Number of countries included: 12
(3 excluded for lack of data)
o Nodes: 20; Terminal nodes: 13
o Tree depth: 3
• Gain Index: Percentage represents the increased
probability of prompt and effective treatment in each
terminal node.
Table 1: Availability of Information
Figure 2: Antimalarial Treatment Among Children
Figure 1: Countries & Surveys Included
Node Best Predictor p-value
1 Maternal education 0.009
2 Maternal education <0.0001
3 Wealth index <0.0001
4 None n/a
5 Maternal age <0.0001
6 Place of residence (rural or urban) <0.0001
Photo credit: Fadhili Akida
0 20 40 60 80 100
Angola
Benin
Ethiopia
Ghana
Kenya
Liberia
Madagascar
Malawi
Mali
Mozambique
Rwanda
Senegal
Tanzania mainland
Uganda
Zambia
Zanzibar
Children with fever in the two weeks before the survey who received any antimalarial
Children who received ACT among those who received any antimalarial
Country Antimalarial
Time to
treatment
Treatment
duration
Source of
treatment Had Fever
Angola Yes Yes Yes Yes 2,645
Benin* Yes Yes* Yes Yes 4,204
Ethiopia Yes No No Yes 2,082
Ghana Yes Yes Yes Yes 751
Kenya Yes Yes Yes Yes 1,385
Liberia Yes Yes No Yes 1,617
Madagascar Yes Yes Yes Yes 959
Malawi Yes Yes Yes Yes 676
Mali Yes No No Yes 705
Mozambique Yes Yes Yes Yes 1,313
Rwanda Yes Yes No Yes 1,332
Senegal Yes Yes No Yes 2,314
Tanzania mainland Yes Yes No Yes 1,320
Uganda Yes Yes No Yes 2,860
Zambia Yes Yes Yes Yes 1,034
Zanzibar Yes Yes No Yes 282
Note: *ACTs were not yet rolled out in Benin, so the recommended first-line treatment was still
chloroquine. Information is available for other antimalarial treatment but not for ACT treatment.
Node 1: Angola, Ghana, Zambia
Category % N
After 24 hrs 45.9 633
Within 24 hrs 54.1 747
Total 16.3 1,380
Node 2: Kenya, Madagascar
Category % N
After 24 hrs 53.7 262
Within 24 hrs 46.3 226
Total 5.7 488
Node 3: Liberia
Category % N
After 24 hrs 39.8 356
Within 24 hrs 60.2 539
Total 10.5 895
Node 4: Malawi, Rwanda,
Senegal, Tanzania
Category % N
After 24 hrs 28.9 381
Within 24 hrs 71.1 936
Total 20.8 1,317
Node 5: Mozambique,
Zanzibar
Category % N
After 24 hrs 19.6 80
Within 24 hrs 80.4 328
Total 6.4 408
Node 6: Uganda
Category % N
After 24 hrs 32.9 609
Within 24 hrs 67.1 1,240
Total 29.2 1,849
Node 0: Time to ACT treatment
Category % N
After 24 hrs 36.6 2,321
Within 24 hrs 63.4 4,016
Total 100.0 6,337
Country
P-value <0.0001