Measuring coverage in MNCH: accuracy of measuring diagnosis and treatment of childhood malaria from household surveys in Zambia

PLoS Med. 2013;10(5):e1001417. doi: 10.1371/journal.pmed.1001417. Epub 2013 May 7.


Background: To assess progress in the scale-up of rapid diagnostic tests and artemisinin-based combination therapies (ACTs) across Africa, malaria control programs have increasingly relied on standardized national household surveys to determine the proportion of children with a fever in the past 2 wk who received an effective antimalarial within 1-2 d of the onset of fever. Here, the validity of caregiver recall for measuring the primary coverage indicators for malaria diagnosis and treatment of children <5 y old is assessed.

Methods and findings: A cross-sectional study was conducted in five public clinics in Kaoma District, Western Provence, Zambia, to estimate the sensitivity, specificity, and accuracy of caregivers' recall of malaria testing, diagnosis, and treatment, compared to a gold standard of direct observation at the health clinics. Compared to the gold standard of clinic observation, for recall for children with fever in the past 2 wk, the sensitivity for recalling that a finger/heel stick was done was 61.9%, with a specificity of 90.0%. The sensitivity and specificity of caregivers' recalling a positive malaria test result were 62.4% and 90.7%, respectively. The sensitivity and specificity of recalling that the child was given a malaria diagnosis, irrespective of whether a laboratory test was actually done, were 76.8% and 75.9%, respectively. The sensitivity and specificity for recalling that an ACT was given were 81.0% and 91.5%, respectively.

Conclusions: Based on these findings, results from household surveys should continue to be used for ascertaining the coverage of children with a fever in the past 2 wk that received an ACT. However, as recall of a malaria diagnosis remains suboptimal, its use in defining malaria treatment coverage is not recommended.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Antimalarials / therapeutic use*
  • Artemisinins / therapeutic use*
  • Caregivers / psychology
  • Chi-Square Distribution
  • Child Health Services / standards*
  • Child, Preschool
  • Cross-Sectional Studies
  • Developing Countries*
  • Drug Therapy, Combination
  • Family Characteristics
  • Female
  • Health Care Surveys / standards*
  • Health Knowledge, Attitudes, Practice
  • Health Services Research / methods
  • Health Services Research / standards*
  • Humans
  • Infant
  • Infant, Newborn
  • Malaria / diagnosis*
  • Malaria / epidemiology
  • Malaria / therapy*
  • Male
  • Mental Recall
  • Middle Aged
  • Parasitology / methods*
  • Predictive Value of Tests
  • Program Evaluation
  • Reproducibility of Results
  • Research Design
  • Surveys and Questionnaires
  • Time Factors
  • Treatment Outcome
  • Young Adult
  • Zambia / epidemiology


  • Antimalarials
  • Artemisinins
  • artemisinin

Grants and funding

This work was funded by the Malaria Control and Evaluation Partnership in Africa (MACEPA), a PATH project, from funding from The Bill & Melinda Gates Foundation. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.