Agricultural Work, Malaria Prevalence, and Mediating Factors: A Cross-Sectional Analysis of Data from 15 Sub-Saharan African Countries to Inform Risk Stratification and Intervention Planning

Background Although linkages between agricultural work and malaria have been widely studied, country-specific information on disease burden, intervention use, and the pathways through which adult agricultural work affects the health of children in the same household remains limited. This study examines the relationship between agricultural work, malaria infection, and related factors among children under five, highlighting subnational variation across urban and rural areas within each country. Methods Demographic and Health Survey data from 15 sub-Saharan African countries were analyzed to generate descriptive statistics on malaria prevalence, bed net use, and household, age-related, and environmental characteristics of sampled children. Potential mediators were identified by examining their associations with both self-reported agricultural occupation of an adult household member and malaria positivity. Mediation analysis was conducted using logistic regression models within a Structural Equation Modeling framework to estimate indirect, direct, and total effects. The percentage mediated was calculated using percentile bootstrapping. Results Children in agricultural households face a higher risk of malaria than those in non-agricultural households, despite similar rates of bed net use. Substantial country-level variation in malaria prevalence and net use underscores the complex interplay between agricultural occupation, intervention uptake, and malaria risk. Although less common overall, urban agricultural households remain concentrated in populous regions of several countries. Mediation analysis identified wealth, enhanced vegetation index, treatment-seeking behavior, and housing quality as the strongest mediators of this relationship in both urban and rural settings. Conclusions These findings offer actionable insights for countries aiming to better target malaria interventions, particularly in urban areas. The varied mediating factors highlight the need for an integrated approach that addresses housing quality, environmental risk, treatment-seeking behavior, and socioeconomic conditions to protect young children in agricultural households and strengthen malaria control efforts amid shrinking resources.