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CHAPTER TWO: LITERATURE REVIEW
2.0 Introduction
This chapter reviews existing literature on malaria, focusing on its impact on children under five years of age. The discussion is structured around the study’s objectives, drawing on scholarly works and empirical evidence.
2.1 Malaria Distribution Among Children Under Five
Malaria remains a leading cause of illness and death worldwide, particularly among young children in Africa. As a preventable and treatable parasitic disease (US PMI, 2009), various interventions have been implemented at individual, household, and community levels to reduce its burden (Warrell et al., 2002). Key strategies include Artemisinin-based Combination Therapies (ACTs), Long-Lasting Insecticidal Nets (LLINs), Intermittent Preventive Treatment in pregnancy (IPTp), and Indoor Residual Spraying (IRS). These measures have significantly lowered malaria-related risks, especially for vulnerable groups such as pregnant women and children under five.
Malaria prevalence among young children has been documented in multiple studies across developing nations. In the Democratic Republic of Congo, blood smear positivity rates doubled from 17% in the 1980s to 34% by 2000. Similarly, Tanzania’s 2007-08 Malaria Indicator Survey revealed that 18% of under-five children tested positive for malaria, with rural areas (20%) experiencing higher rates than urban zones (8%). Regional disparities were notable, ranging from 0.4% in Arusha’s highlands to 41.1% in Kagera. Prevalence also increased with age—from 9% in infants (6-11 months) to 22% in children aged 2-4 years—and correlated with maternal education and household wealth (THMIS, 2007-08).
Globally, over 30,000 malaria cases are reported annually among travelers from developed nations visiting endemic regions (Leder et al.). Malaria and poverty are closely linked, with malarious countries having an average GDP per capita five times lower than non-malarious nations (WHO, 2013). According to the Global Malaria Action Plan, 3.4 billion people—half the world’s population—live in malaria-prone areas. In 2012, malaria caused 207 million clinical cases and 627,000 deaths, 91% of which occurred in Africa.
In Uganda, malaria is the primary driver of morbidity and mortality in children under five, accounting for 70% of outpatient visits and over 50% of hospital admissions. Annual child deaths range between 70,000 and 110,000, with higher fatality rates in high-transmission areas (37 deaths per 1,000 live births) compared to low-endemic zones (18 deaths per 1,000). Refugees and internally displaced persons in Uganda are also severely affected.
Gender disparities in malaria management further exacerbate the problem. Studies indicate that women often have limited decision-making power regarding healthcare, leading to treatment delays (Al-Taiar et al., 2009; Oberlander & Elverdan, 2000). Since women are primary caregivers, these delays disproportionately harm children.
2.2 Regional and Socioeconomic Disparities in Malaria Prevalence
Malaria disproportionately affects impoverished communities, exacerbating cycles of poverty (Makundi et al., 2007). Households often sell assets to cover treatment costs, worsening food insecurity and debt (Wandiga et al., 2006). The economic burden is regressive, with poorer families spending a larger share of their income on malaria care than wealthier counterparts.
The World Malaria Report 2015 (WMR) estimates that 3.2 billion people are at risk of malaria, with 1.2 billion facing high exposure. In 2015, Africa bore 88% of the global malaria burden (214 million cases), followed by Southeast Asia (10%) and the Eastern Mediterranean (2%). Deaths totaled 438,000, with 90% occurring in Africa.
Socioeconomic factors critically influence malaria transmission. Poor education and limited resources hinder effective prevention and treatment (Collins et al., 1997; Yadav et al., 1999). Filmer (2002) found that impoverished individuals often delay seeking care due to cost barriers, relying on lower-quality public facilities.
Health education is vital for malaria control, yet many programs lack effective communication strategies (Mboera et al., 2007). Communities and healthcare providers must understand malaria’s risks and available interventions to combat it effectively.
In Uganda, malaria is hyperendemic, with 90% of the population at risk. Transmission rates are among the highest globally, peaking at 1,586 infective bites per person annually in Apac District (Okello et al., 2006). The 2009 Uganda Malaria Indicator Survey (UMIS) found parasitemia rates of 30–50% in children under five, with severe anemia (hemoglobin <11 g/dl) prevalent in over half of cases. Urban areas like Kampala reported lower prevalence (5%), while rural regions exceeded 38%. Higher maternal education and wealth correlated with reduced infection rates.
2.3 Malaria Trends and Forecasting Challenges
Due to inconsistent malaria data in sub-Saharan Africa, infection prevalence surveys and modeling help estimate transmission levels. In 2013, an estimated 128 million people in the region carried Plasmodium falciparum infections, with Nigeria and the Democratic Republic of Congo accounting for 40% of cases.
Uganda’s reported malaria cases surged from 1.4 million in 1995 to 2.9 million in 1999 (WMR, 2012). By 2015, rising drug resistance and chronic infections had worsened outcomes, particularly anemia in children and pregnant women (PMI, 2009). Severe malarial anemia causes 8–25% of pediatric deaths and 60% of miscarriages.
Despite global progress toward malaria elimination, Uganda’s burden remains high. Kampala has seen anecdotal declines, attributed to bed nets and effective treatments (Clark et al., 2010). However, Health Management Information System (HMIS) data are unreliable due to underreporting and misdiagnosis (Rowe et al., 2009). Factors like free public healthcare (since 2001) and community-based fever management have further complicated trend analysis. With Uganda’s growing population, stable case numbers suggest a slight per capita decline, but malaria incidence remains critically high.
