title: Disparities between malaria infection and treatment rates: Evidence from a cross-sectional analysis of households in Uganda.
abstract: BACKGROUND
  In Sub-Saharan Africa, both under-treatment and over-treatment of malaria are common since illnesses are often diagnosed and treated on the basis of symptoms. We investigate whether malaria treatment rates among febrile individuals correspond to observed patterns of malaria infection by age and by local prevalence.
  
  
  RESULTS
  We use data on treatment of febrile illnesses from a household survey that was conducted between March and May 2012 in 92 villages in six districts in Eastern Uganda. All household members were also tested for malaria using a rapid diagnostic test. We show that both the age of the febrile individual and the village prevalence rate are strongly associated with the odds that a febrile patient was infected with malaria, but not with the odds of ACT treatment. Compared to individuals who were aged 15 or above, febrile individuals aged 5-14 had 3.21 times the odds of testing positive for malaria (95% CI: [2.36 4.37], P<0·001), and febrile individuals who were under age 5 had 2.66 times the odds of testing positive for malaria (95% CI: [1.99 3.56], P<0·001). However, ACT treatment rates for febrile illnesses were not significantly higher for either children ages 5-14 (Unadjusted OR: 1.19, 95% CI: [0.88 1.62], P = 0.255) or children under the age of 5 (Unadjusted OR: 1.24, 95% CI: [0.92 1.68], P = 0·154). A one standard deviation increase in the village malaria prevalence rate was associated with a 2.03 times higher odds that a febrile individual under the age of five tested positive for malaria (95% CI: [1.63 2.54], p<0·001), but was not significantly associated with the odds of ACT treatment (Un-adjusted OR: 0.83, 95% CI: [0.66 1.05], P = 0·113). We present some evidence that this discrepancy may be because caregivers do not suspect a higher likelihood of malaria infection, conditional on fever, in young children or in high-prevalence villages.
  
  
  CONCLUSIONS
  Our findings suggest that households have significant mis-perceptions about malaria likelihood that may contribute to the under-treatment of malaria. Policies are needed to encourage caregivers to seek immediate diagnostic testing and treatment for febrile illnesses, particularly among young children.
authors.affiliation: Duke Global Health Institute, Duke University, Durham, NC, United States of America.
authors.forename: Indrani
authors.initials: I
authors.lastname: Saran
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.
authors.forename: Jessica
authors.initials: J
authors.lastname: Cohen
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003955:Diagnostic Tests, Routine; D005260:Female; D005334:Fever; D054625:Healthcare Disparities; D006801:Humans; D007223:Infant; D008288:Malaria / Q000453:epidemiology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D015995:Prevalence; D012044:Regression Analysis; D016896:Treatment Outcome; D014454:Uganda; D055815:Young Adult
chemical_list: D000962:Antimalarials