Abstract:
Background: Maximizing the impact of community-based programs requires understanding how the
supply of and demand for the intervention interact at the point of delivery. We present results from a
large-scale community health worker study designed to increase the availability of and demand for
malaria diagnostic testing in a rural, malaria-endemic region in western Kenya between 2015 and 2017.
Methods: Community Health Workers (CHWs) provided free malaria Rapid Diagnostic Test(mRDT) in the
community. Those with a positive malaria test were provided with a discounted first-line antimalarial
over-the-counter. We conducted a community-based survey to collect individual study outcomes at 12-
and 18-months post-implementation. In addition, we collected monthly testing data from the 244
participating CHWs and also conducted in-depth interviews with a random sample of 70 CHWs.
Results: From the survey, 55% (n=948/1738) reported having a malaria test for their recent illness with
38% having been tested by a CHW. Being aware of a local CHW (95% CI:1.10-2.04) and belonging to a
wealthy household (95% CI:1.14-2.06) were associated with higher malaria testing uptake from any
source. Poorer households were more likely to receive a test from a CHW. School-aged children between
5-17 years were more than twice as likely to be tested by a CHW (95% CI:1.47-4.14). Both confidence in AL
treatment (95% CI:1.54-4.92) and perceived accuracy of an RDT performed by a CHW (95% CI:1.12-5.27)
were strongly and positively associated with testing by a CHW. In adjusted analyses, specific CHWs
attributes were significantly associated with higher testing rates including formal employment (95%
CI:0.05-2.70), those serving more than 50 households (95% CI:0.70-2.74) and those serving areas with a
higher proportion of positive tests (95% CI:1.05, 3.22). On both the supply side and the demand side,
confidence in a test performed by a CHW was strongly correlated with the success of the intervention.
Conclusion: Scale-up of community-based malaria testing intervention through CHWs is feasible and
effective at reaching the poorest households. In order to maximize the impact of such interventions, it is
important to recognize factors that may restrict both delivery and demand for such services.