Early detection and treatment of malaria contributes to reduced complications and deaths (1). A mixed approach of providing health services at both health facility and community levels is appropriate where only about 70% of people in Sub-Saharan Africa use public facilities as the first point of care when a family member has fever (1).
Globally, given the limited human resources in the health sector, the community-based approach has been promoted as a cost-effective and pro-poor intervention to improve the accessibility of healthcare (2), (3) and (1). This underscores the importance of community health volunteers (CHVs) as a key element in the community-based approach to most populations in low- and middle-income countries (4). CHVs are generally defined as non-professional lay health workers who work in the communities where they reside, and who are equipped with training and incentives to provide promotional, preventive and curative healthcare services to community members (5), Bhattacharyya et al., 2001 and (6)
In Kenya, CHVs are recruited at community meetings (barazas) called by area leaders or community health committees (CHC), using set criteria. (7). CHVs are organised into community units (CUs) supervised by community health extension workers (CHEWs). Each CHV provides services to an average of 100 households, linking them to the formal health sector; about 5,000 community members are served by CHVs within each community unit (Kimberly, Kristen, & Tanvi, 2017); (8).
Community case management of malaria (CCMm) is an equity-focused strategy that complements and extends the reach of health services by providing timely and effective diagnosis and treatment to populations with limited access to facility-based healthcare (9). In Kenya, the CCMm strategy utilizes CHVs who have received training on performing and interpreting malaria rapid diagnostic tests (mRDT) and prescribe artemether lumefantrine (AL) to confirmed, uncomplicated malaria cases. CHVs refer pregnant women with suspected malaria, suspected severe malaria cases, patients with negative malaria test results and patients with persistent symptoms to health facilities for further management.
In western Kenya, a malaria endemic zone, CCMm has been adapted increasingly since 2012 as an approach to increase timely access to malaria care and treatment. About 7,420 CHVs have been trained and equipped with health commodities and tools to promptly diagnose and treat uncomplicated malaria cases at community level and help prevent progression to severe life-threatening disease. CHVs are also trained to identify severe malaria cases for early referral and thus help reduce malaria deaths. CHVs are part of the first level of national malaria monitoring, and conduct epidemiological surveillance of malaria cases at community level. CHVs submit monthly reports to the Kenya Health Information System (KHIS) and thus contribute to the national malaria control strategy with up-to-date information (10).
Symptom-based malaria diagnosis is inaccurate and contributes to poor management of febrile illness, over-treatment of malaria, and may promote drug resistance to current anti-malarial drugs (11). The World Health Organization recommends testing of all suspected malaria cases before treatment as best practice in malaria case management (12). The 2019–2023 Kenya Malaria Strategy emphasises this recommendation with testing in healthcare facilities using microscopy and mRDT (13). While microscopy is the diagnostic test of choice in health facilities with laboratories, mRDTs are used in facilities where microscopy is unavailable due to several factors such as lack of microscopes, trained laboratory personnel or electricity. Testing of malaria in the community setting is entirely by mRDT with the intention of reducing the practice of presumptive malaria treatment and irrational use of malaria treatment drugs.
While microscopy detects the presence of malaria parasites in blood by direct observation, mRDT detects the presence of circulating malaria parasite antigens. The most commonly used mRDT detects Plasmodium falciparum-specific histidine-rich protein 2 (PfHRP2) while others detect lactate dehydrogenase (LDH) and aldolase. mRDT results may remain positive for a variable amount of time (5–61 days) following effective treatment with anti-malarial drugs, depending on the type of mRDT used, age and treatment, thereby affecting their specificity (14). Sensitivity is associated with the inherent performance of the test, as well as quality issues related to handling of test kits and the performance of the testing procedure. Although CHVs undergo training on the use of mRDT, storage and transport conditions and human error may affect the validity of the test results. Procedural factors include the quality of the blood drop as well as the time taken by the operator to read the test results (15)
The National Malaria Control Programme uses routine surveillance data reported in the Kenya Health Information System (KHIS) to produce a quarterly Malaria Surveillance Bulletin. In the July to September 2018 issue, the all-age malaria test positivity rate (TPR) was 24% with the TPR in the malaria lake endemic zone being comparatively high at 35% (16). However, these data are not disaggregated to facilities or community level. From the CCMm routine data reported for the same period, the average TPR for malaria RDTs performed by CHVs in the malaria lake endemic zone was almost twofold at 67%. There was therefore a need to evaluate the performance of CHVs in conducting RDTs and determine the accuracy of their reports in comparison with tests performed by qualified laboratory personnel.