Achievements in malaria prevention and control in Uganda: a scoping review

Achievements in malaria prevention and control in Uganda: a scoping review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Achievements in malaria prevention and control in Uganda: a scoping review Sarah Nalinya, David Musoke, Suzan Nakalawa, Simple Ouma, Catherine Maiteki Ssebuguzi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7802394/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Uganda ranks among the top five countries with the highest global burden of malaria cases and deaths. Although Uganda has made progress in the scale up of key malaria control interventions, there remains a significant gap in achieving universal coverage for impact. By the end of 2025, the National Malaria Control Division (NMCD) aimed to reduce malaria morbidity by 50% and malaria related mortality by 75% of the 2019 levels. Aim The aim of this scoping review was to examine available literature on malaria prevention and control in Uganda to gain an insight on the progress, identify gaps and opportunities on the implementation of control strategies. This aimed to inform practice, policy and programs and provide direction for future research priorities to propel the country to malaria elimination. Methodology: The study involved reviewing published on malaria indicators from the year 2000 to 2024. Literature was obtained from PubMed, the Cochrane Library, Uganda Demographic Health Surveys, Uganda Malaria Indicator Surveys, Malaria Program Reviews and other sources. The search strategy included all study designs and was limited to those in English. Three independent reviewers performed the selection and characterization of articles, and the data was qualitatively synthesized. Results A total of 3,619 articles were identified and 38 were included in the analysis. The results were grouped into 3 major themes of: knowledge; practices; and policies for malaria prevention and control. The level of knowledge among adults on the different aspects of malaria was generally high and has increased over the past two and half decades. Coverage of interventions have remarkably improved over the years. Ownership of LLINs significantly increased from 13% in 2001 to 95% in 2021. The use of long-lasting insecticidal nets (LLINs) was at 69% in 2021. Intermittent preventive treatment for malaria during pregnancy (IPTp) have increased but still below the target, from 16% in 2006 to 72% in 2019. Seasonal Malaria Chemoprevention has been piloted with promising results. Progress on environmental management and integrated community case management of childhood illnesses for malaria control has been slow. Various malaria policies have been adopted such as universal coverage for LLINs, and artemisinin combination therapies for uncomplicated malaria. Conclusion Uganda has made significant progress on different malaria prevention and control indicators. However, coverage of interventions is suboptimal to achieve malaria elimination. Innovations are needed in malaria control coupled with a multi-sectoral approach and political commitment to achieve malaria elimination. Malaria prevention control elimination integrated vector management Uganda Figures Figure 1 Introduction Although the National Malaria Control Programme (NMCP) in Uganda has achieved significant progress on key malaria control indicators over the past twenty-five years, malaria remains the leading cause of morbidity and mortality in the country [ 1 , 2 ]. Uganda consistently ranks among the top five countries with the highest global malaria infection rates [ 3 ]. Malaria is of key public health importance because any delay in treatment can lead to serious health complications as well as death. In addition, the social and economic impact of malaria is significant, with care costs alone estimated at US $ 9 per person per episode [ 1 ]. An average household spends approximately 3% of its monthly income to manage a malaria episode [ 1 , 4 ]. Other costs incurred at individual, household, community and national level include missed school and workdays [ 5 , 6 ], and loss of foreign direct investment [ 1 ]. Although progress has undeniably been made in the scale-up of key technical and supportive interventions to control malaria in Uganda, there remains a significant gap in achieving universal coverage for impact [ 1 ]. To reduce the occurrence of malaria in the country, the Ministry of Health (MOH) through NMCP has five main intervention strategies: malaria case management; Intermittent Preventive Treatment during pregnancy (IPTp); environmental management including vector control; epidemic preparedness and response; and information, education and communication (IEC) including social mobilization [ 7 ]. The NMCP routinely sets targets for assessing progress on malaria indicators and preparing for the pre-elimination stages of the disease in Uganda. The current goal of the NMCP is to reduce malaria morbidity by 50% and malaria related mortality by 75% of the 2019 levels by the end of 2025 [ 1 ]. The core interventions for attaining the NMCP goal profoundly relies on use of long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS), and case management [ 8 , 9 ]. MOH regularly conducts mass distribution of LLINs mainly to households with children five years and pregnant women [ 10 , 11 ]. In addition, IRS has been scaled up in selected 15 high burden districts in West Nile, Northern and Eastern Uganda [ 12 , 13 ]. Community case management through community health workers was rolled out especially in rural areas to promptly diagnose and treat malaria in children aged under five years [ 13 , 14 ]. Other interventions of integrated vector management (IVM) such as environmental management, improvement of housing design, and larval source management are currently implemented on a small scale [ 15 ]. As Uganda moves towards malaria pre-elimination, there is a paucity of synthesized and summarized literature on the country’s 25-year progress on all the different malaria prevention and control strategies since the scaling up of major interventions in 2000. The objective of this scoping review was therefore to examine available literature on progress on malaria prevention and control in Uganda, understand the evolution of national control strategies and to map progress for various indicators. In addition, the review aimed at identifying gaps and opportunities for further malaria prevention and control in Uganda as the country moves towards the ambitious goal of elimination of malaria. Methodology Search strategy A comprehensive search across a range of databases, organisational websites, and conference abstract repositories was conducted. The databases searched included PubMed, The Cochrane Library, and Social Science abstracts. More studies were obtained through a manual search of references listed in the retrieved studies. The search also included grey literature to obtain information that was not present in commercial publications, and those aimed at a limited audience [ 16 ]. Specifically, searches were done on Google and websites of agencies that fund, implement or report about malaria in Uganda. Keywords used in the search included: malaria, Plasmodium falciparum , Plasmodium vivax , knowledge, attitude, practices, perception, mosquito net, bed net, insecticide treated bednets (ITNs), practice, misuse, acceptability, belief, Uganda, achievements and milestones. The search strategy included publications for a 24-year period (2000 to 2023). The search was limited to English language due to the large number of identified knowledge sources. The study team also sent out personalised requests via email to contacts in MOH and specifically the National Malaria Control Programme to provide any relevant literature. Following a predetermined inclusion criterion, three authors (SN, DM, AY) independently identified different knowledge sources such as published articles, unpublished articles, policy documents, commentaries, and reports for inclusion in the review. The identified articles were peer reviewed and approved by other authors guided by the evidence-based checklist of Peer Review of Electronic Search Strategies [ 17 ]. The articles mainly focused on the prevalence on malaria in Uganda; knowledge, attitudes and practices of malaria prevention and control; as well as emergency planning and the policy environment surrounding malaria prevention and control in Uganda. Study selection criteria All study designs, including qualitative and quantitative studies, policy guidelines, and reports were considered eligible for this scoping review. Although the scoping review was focused to include studies conducted on malaria in Uganda, international documents such as WHO and UNICEF reports were included. The selection criteria for this scoping review followed the population, concepts and context (PCC) format [ 18 ] as described below. Population (P) Studies which were conducted in Uganda and assessed the social and medical epidemiology of malaria were included irrespective of age, gender or any other characteristics of the study participants. Physical, ecological and conceptual populations were included in the review. Concepts (C) All studies which explored interventions aimed at preventing or controlling malaria were included. The interventions were summarized into the following categories: (i) health promotion / education; (ii) testing and treatment; (iii) surveillance and mitigation; (iv) vector control; and (v) health policy. Contents (C) This review included published and unpublished studies, assessing interventions for malaria prevention and control, case studies, as well as policy documents relating to malaria prevention and control in Uganda. The resulting knowledge sources were from 2000 and 2023. The first search was conducted in May 2019, and updated searches were conducted in November 2019, June 2022 and later in January 2024. Information sources which mainly focused on subjects rather than malaria prevention and control in Uganda were excluded. Data extraction The authors of this review conducted data extraction in several steps. First, three authors (SN, DM and AY) independently evaluated the article titles followed by their abstracts. They then selected full-text articles according to the selection criteria. A data extraction form was developed by the three authors. The form was then pre-tested by the authors on a sample of articles to verify its ease of use and completeness. The form was then used by one author (SN) to extract the relevant data from each included knowledge source. The extracted information was discussed by all authors, and a consensus was reached. Information collected were: first author, publication year, methods used, location and setting, size and characteristics of sample, interventions, study variables, and results or outcomes. Data synthesis For the qualitative analysis, one author (SN) conducted the initial categorisation of the key components using Atlas.ti 8 [ 19 ]. Details of the included knowledge sources were combined as a narrative by the study topic and results. The final categorisation was discussed by the entire research team [ 20 ]. Upon discussion of the preliminary categorization, a coding framework was developed by all the authors. Two authors (SN and DM) coded and categorised the relevant data units from the knowledge sources into sub-themes and themes using the framework developed by the team. Replicability of the search The study team had a clear plan describing what we felt was a comprehensive and possibly replicable approach to searching for the knowledge sources used in this article. However, it is difficult to claim that this would result into replicable findings. Although future studies may be able to replicate our search methods, it is unlikely that they will obtain the same results, as would be expected when searching electronic databases [ 16 ]. Methodological quality appraisal The study team did not evaluate the methodological quality or bias risk of the included knowledge sources, which is consistent with guidance on conducting scoping reviews [ 21 ]. Results The data search resulted in a total of 3,619 articles. We analysed all these articles using their titles and abstracts, and 72 information sources through reading in full. After removing duplicates and applying the PCC selection criteria, we selected 38 information sources that were included in this scoping review (Fig. 1 ) Knowledge on malaria The level of knowledge among malaria caregivers on the different aspects of malaria such as the cause, spread, signs, symptoms, prevention and treatment of cases in Uganda was generally high and increased over the past two decades. For example, national reports indicated that knowledge of malaria spread through mosquito bites increased from 78% to 91% between 2009 and 2019 [ 12 , 22 , 23 ]. Several studies have also shown that knowledge on the signs and symptoms of uncomplicated malaria, such as fever and body weakness was generally high and widespread across the country [ 24 , 25 , 26 , 27 , 28 , 29 ]. The proportion of women who reported that a child with fever should be treated immediately increased from 67% in 2009 [ 23 ] to 77% in 2019 [ 12 ]. Indicators for knowledge on malaria prevention have also significantly improved, with 94% of women being aware of malaria prevention methods in 2019 [ 12 ]. Other studies [ 30 , 31 ] have also shown that knowledge on malaria prevention has improved in various parts of Uganda. On the other hand, knowledge on IPTp has had relatively slow progress over the past two decades. In 2009, the knowledge on IPTp was at 7% [ 23 ], which slightly increased to 9.3% in 2015 [ 22 ], and substantially increased to 49% in 2019 [ 12 ]. Practices on malaria prevention and control Malaria testing and treatment Proper and accurate malaria testing and diagnosis is essential for ensuring appropriate treatment in parasite-positive individuals. Until 2008, malaria diagnosis in most of Uganda's primary health care settings heavily relied on clinical symptoms [ 32 ], while the diagnostic laboratory infrastructure using microscopy existed only in major district, regional and national hospitals. This posed substantial challenges in effective malaria diagnosis in primary healthcare settings until the laboratory infrastructure was expanded to lower-level health centres. Laboratory infrastructure was introduced to lower-level primary healthcare settings, specifically HCIIIs and HCIVs through the Uganda National Minimum Health Care Package (UNMHCP) program in 2008 [ 33 ]. However, diagnostic testing remained very limited due to numerous factors such as shortage of trained staff and equipment. In 2009, Uganda adopted Rapid Diagnostic Tests (RDTs) to complement microscopy, following the WHO recommendation to rely on parasitic testing and move away from symptom-based malaria diagnosis [ 33 ]. Malaria testing among suspected cases was only at 24% in 2010 and substantially increased to 59% in 2013 [ 34 , 35 ]. This increase correlated with the increased availability of RDTs in most primary healthcare settings. The current policy recommends parasitology testing using either microscopy or RDTs. Although the choice of the method depends on the level of the health facility and the availability of trained staff and supplies, microscopy remains the reference method for malaria diagnosis in Uganda [ 36 ]. The roll-out of RDTs for diagnosis of malaria under Integrated Case Management (ICCM) is being implemented [ 37 ]. The improvement of parasitic-based diagnosis of malaria, especially RDTs has enhanced diagnostic testing and hence boosted the rational use of ACTs. Uganda aimed, through the 5-year (2014–2020) malaria reduction strategy, to have at least 75% of suspected malaria cases having parastic testing in 2019, and the target increased to 84% in 2021 [ 8 ]. Indeed, the proportion of suspected malaria cases parasitically tested in public and private-not-for-profit health facilities increased from 59% in 2013 to 88% in 2017, and 97% in 2022 [ 37 ]. Testing of suspected malaria cases in private health facilities increased from 31% in 2013 to 44% in 2017 [ 38 ]. ICCM was used to boost malaria testing in the community. The proportion of suspected malaria cases tested in the community under iCCM increased from 80% in 2011 to 95% in 2017 but decreased to 92% in 2019 and 89% in 2022 [ 38 ]. Effective case management, including prompt and appropriate treatment with affordable, effective, and safe antimalarials, remains a cornerstone of malaria control in Uganda. The combination of CQ and SP became the first-line regimen for uncomplicated malaria in 2001, but unsurprisingly the efficacy of this combination of sub-optimal therapies was ineffective [ 39 , 40 ]. In 2004 the first-line therapy was changed to ACTs, with artemether-lumefantrine (AL; Coartem) routinely available and artesunate plus amodiaquine (ASAQ) as an alternative first-line treatment [ 41 ]. Quinine was recommended as the second-line treatment. However, ensuring availability and proper use of ACTs at all facilities countrywide present some challenges. The main challenge for effective malaria treatment at public facilities is prolonged stock-outs of ACTs and non-compliance to treatment guidelines [ 42 ]. The new National Malaria Control Policy emphasises parasite-based diagnosis before treatment, change from IV quinine to IV artesunate in the treatment of severe malaria, replacing oral quinine with Dihydroartemisinin/Piperaquine (DP) as second line treatment for uncomplicated malaria and use of rectal artesunate for pre-referral treatment of severe malaria [ 42 ]. During the past years, ACTs of various forms have been available in the private sector but at prices not affordable by most of the population. A pilot project to deliver subsidized medicines in the private sector started in 2008. Between 2008 and 2018, the price of ACTs reduced from USD 8.8 to USD 1.1 [ 43 ]. Research showed that availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities between 2007 and 2018 [ 43 ]. This pilot, supported by MMV, demonstrated that providing subsidized ACTs through the private sector, where about 60% of patients first seek care, can lead to a significant increase in availability and uptake of effective treatment. Evidently, the 2009 UMIS reported that among children under five years with fever, 60% took an anti-malarial drug, and of these, 23% took an ACTs. [ 23 ]. ACTs use continually improved and by 2014, about 87% of children under five years with fever in the last two weeks preceding the survey, took an ACT [ 22 ]. The programme continued to register an improvement in the proportion of confirmed malaria cases that received ACTs at health facility level. In 2022, 99% of the patients attending health facilities with malaria received ACTs. The proportion of confirmed malaria cases that received ACTs in the community increased to 90% by 2022. Long lasting insecticidal nets (LLINs) Use of ITNs is a cornerstone of the NMCP’s malaria control strategy in Uganda. The NMCP has pursued multiple strategies to increase ownership and use of nets, including free distribution to pregnant women through antenatal care visits, provision of subsidized ITNs through the private sector, sale of full-cost ITNs in the commercial sector and free mass distribution campaigns to achieve 100% coverage of all households (having one net per two people). The NCMP supports a public/private mix approach using all available mechanisms for distribution, sales and promotion of LLINs, including free LLIN distribution to households by mass campaign at intervals of three years, replacements of LLINs through ANC and Expanded Program on Immunizations (EPI) outlets, subsidized sales mainly through civil society and commercial sales through the private sector. MOH had targets to achieve LLIN access of 85% in 2014 and 2017, and 100% in 2021 through LLIN mass distribution campaigns [ 1 , 44 ]. Although LLIN coverage registered was slightly below target following two of the three campaigns, Uganda generally registered a remarkable increase in ownership of at least one LLIN per household, from 13% in 2001 to 90% in 2015 [ 22 ], 83% in 2019 [ 12 ] and then 95% in 2021 [ 38 ]. However, although 90% of households in Uganda owned at least one LLIN in 2015, about 69% of households used them [ 22 ], and this dropped to 59% in 2019 [ 12 ] and then back to 69% in 2021 [ 44 ]. The Government of Uganda also aimed at universal LLIN coverage, where every household owned at least one LLIN for every two people. In 2011, only 28% of households had attained universal LLIN coverage [ 45 ], which increased to 62% in 2015 [ 22 ], and declined to 54% in 2019 [ 12 ]. A study in central Uganda showed that LLIN use among households that had achieved universal LLIN coverage was 80% [ 31 ], but there was limited literature for other regions of the country. Uganda has registered remarkable progress in use of LLINs among children under five years and pregnant women in the past two decades. These significant increases have largely been due to the MOH initiative to distribute free LLINs [ 12 , 34 , 35 ]. The number of children under five years who slept under a LLIN significantly increased from 8% in 2001 [ 45 ] to 75% in 2015 [ 22 ] but reduced to 64% in 2016 and 60% in 2019 [ 12 ]. LLIN use among pregnant women steadily increased since 2006 from 10% [ 35 ] to 75% in 2015 [ 22 ]. However, this dropped to 64% in 2016 [ 45 ] and 65% in 2019 [ 12 ]. Intermittent Preventive Treatment in Pregnancy (IPTp) The IPTp strategy has proved to be effective in preventing parasitaemia and anaemia in mothers, and in increasing birth weight thus boosting chances of survival for newborns and mothers [ 46 ]. In the past 15 years, MOH scaled-up IPTp using sulfadoxine-pyrimethamine (SP) / Fansidar as an important component of the malaria control programme [ 47 ]. The current national guidelines recommend at least four ANC visits for all pregnant mothers [ 48 ], during which they take SP / Fansidar at each of the visits [ 13 ]. For the delivery of IPTp, the policy recommends that pregnant women receive SP given monthly, starting from from 13 weeks till delivery. Progress in the recommended uptake of IPTp has been considerably slow but steadily improving [ 22 ]. In 2006, IPTp uptake (at least two doses of SP / Fansidar) was at 16% [ 45 ], which increased to 27% in 2011 [ 34 ], 45% in 2015 [ 22 , 31 ], and 72% in 2019 [ 12 ]. Availability of SP improved significantly from 8% to 80% in 2019 [ 1 ]. Uptake of at least three doses of IPTp increased from 45% in March 2020 [ 49 ] to 60% in September 2022 meeting the target of 58% by 2021/2022. This positive trajectory shows that the targets in the remaining period of the strategic plan are likely to be achieved [ 38 ]. Indoor Residual Spraying (IRS) The NMCP strategy for IRS, has emphasized implementation in epidemic-prone areas, high transmission settings, and high-risk situations. Most recently, attention has moved from epidemic-prone areas to those with very high transmission intensity in northern Uganda [50 Raouf et al., 2017]. Mass IRS campaigns have been in place since 2006 especially in Northern Uganda which has the highest burden of the disease [ 51 ]. In 2009, IRS was mainly scaled up and concentrated in 10 districts in Northern Uganda [ 51 , 52 ], and later to 14 high malaria burden districts in Eastern and Central Uganda [ 22 ]. MOH has updated the IRS target districts to 50 but the programme has been implemented in only 15 due to funding constraints [ 1 ]. In 2009, 32% of households in the scaled-up districts had undergone IRS, and this increased to 66% in 2011 [ 34 ]. In 2015, 75% of households in the districts where IRS had been scaled up had undergone IRS [ 22 ]. MOH had a target to conduct IRS in 30% of households in Uganda by 2018 [ 7 ]. However, this target was not achieved since only 17% of the households underwent IRS in 2017/2018 [ 7 ], and the proportion further declined to 10% in 2018/2019. Community acceptance of IRS has been impeded by various factors including insecticide smell, cost of the insecticide, perceived ineffectiveness, environmental concerns, and side effects [ 53 , 54 ]. In 2020, IRS was conducted across 16 districts in the regions of Bukedi and Mid-Northern Uganda. In 2022, IRS was expanded to 9 districts in West Nile. In 2022, a total of 23 districts received IRS, protecting a population of 15.2%, short of the NSP target of 18.6% [ 38 ]. In 2022, the country experienced a malaria epidemic involving up to 75 districts at the peak of the epidemic. The affected districts included 10 districts (Budaka, Bugiri, Butaleja, Butebo, Kibuku, Namutumba, Pallisa, Tororo, Lira, and Serere ) that deployment a new IRS chemical clothianidin in 2020–2022. Wall bioassays later showed that clothianidin remained efficacious for only 4–6 months depending on the wall surface and yet IRS spraying was done once a year. The IRS chemical was accordingly switched to Actellic 300 CS in alignment with the National Insecticide Resistance Management Plan. Research has also shown that stopping IRS in areas where it had been previously implemented led to significant surge in malaria cases [ 42 ]. For example, the incidence of malaria in Gulu doubled in 2015 after IRS had been stopped in the district in 2014 [ 55 ]. Integrated Community Case Management The Health Sector Strategic Plan 2011–2020 (HSSP) adopted Community Health Workers (CHWs), locally referred to as Village Health Teams (VHTs), to promote the health and well-being among the community in Uganda and bridge the gap in health service provision [ 13 , 14 ]. The goal of this ICCM strategy is to reduce childhood morbidity and especially mortality by providing case management for malaria, pneumonia and diarrhoea to sick children within their communities as well as identifying and referring sick newborn babies. The iCCM strategy was originally concentrated in rural areas but the Uganda Malaria Strategic Plan 2021–2025 aimed to scale-up the intervention to all parts of the country including peri-urban areas. This was premised on increasing access to malaria treatment for hard-to-reach areas and key populations such as refugees and schools [ 1 ]. In 2009, only 18% of households reported knowledge on the existence of a VHT in their community [ 23 ], which doubled to 37% in 2015 [ 22 ] and increased to 54.5% in 2019 [ 1 ]. The proportion of children aged 2 months − 5 years, presenting with a fever who were seen by VHTs and treated within 24 hours improved from 46% in 2020 to 60% in 2022 [ 38 ]. Within ICCM supported districts, there has been a gradual reduction in morbidity and mortality, between 2019/2020 and 2021/2022, inpatient admissions for children under 5-years decreased by 9% from 189,038 to 171,948 and deaths decreased by 35% from 1333 to 866 [ 38 ]. There are however challenges with the iCCM strategy including high workload, religious and cultural practices [ 56 ], interruption in the supply of commodities, low motivation of VHTs, low reporting, and limited integration with other diseases programmes at the community level [ 57 ]. In 2018, Uganda redesigned the VHT strategy by establishing a Community Health Extension Workers (CHEWs) programme that promised to be more functional, sustainable and responsive to health services delivery. While VHTs are operate at a village level and are volunteers, the CHEWs are intended to be based at the parish level, be trained for at least six months, supervise VHTs and receive formal pay for their work [ 58 , 59 ] Larval Source Management (LSM) LSM involves methods of controlling larval or adult mosquitoes using biological control techniques or environmental management [ 60 ]. LSM and larviciding have been implemented on only a small scale in Uganda but the MoH plans to scale-up the strategy especially in urban areas and in the cattle corridor, as these are amenable to the sufficient entomological and geospatial surveillance essential for effective LSM [ 1 ]. Seasonal Malaria Chemoprevention Seasonal Malaria Chemoprevention (SMC), the intermittent administration of a full course of course of anti-malarial medication to children between 3–5 years during high malaria transmission seasons [ 61 ] has been piloted in Karamoja region [ 62 ]. The region, located in North-Eastern Uganda has one prolonged wet season from May to September with over 60% rainfall and 60% malaria transmission [ 63 ]. SMC has been implemented in the Karamoja region from 2021, and it is more appropriate than other malaria prevention and control strategies due to the cultural practices, housing conditions and the nomadic nature of the community [ 64 ]. SMC is implemented by administering 8 full monthly doses of Sulfadoxine Pyrimethamine (SP) and Amodiaquine (SPAQ) during and after the wet season [ 65 ]. SMC has been highly acceptable to stakeholders including; policy makers, implementers, and communities [ 62 ]. SPAQ was found to be very well tolerated by children in Karamoja with no serious adverse reactions reported [ 66 ]. Implementation of SMC significantly reduced incidence of uncomplicated malaria among children under 5 years in Karamoja region [ 65 ]. Policies and international commitments Uganda has adopted, adapted and implemented different malaria prevention and control policies during the past two decades, mostly in line with WHO guidelines. Previously, the NMCP mainly focused on protecting those most vulnerable to malaria particularly children under five years and pregnant women [ 22 ]. Progressively, the focus has shifted towards achieving universal coverage for all interventions [ 5 ]. MOH had a target to achieve universal coverage for LLINs by December 2023 [ 5 ] but this was still below the target [ 31 ], with most recent estimates at 54% [ 12 ]. The MOH policy on IRS recommends that it should only be implemented as part of a long-term vector control or malaria elimination strategy but not as an epidemic control measure [ 13 ]. MOH currently recommends sulfadoxine pyrimethamine (SP) for IPTp, [ 1 ] and every pregnant woman to receive a minimum of three doses of IPTp, with no maximum if they are at least a month apart [ 1 ]. In addition, there is also a newly introduced policy on using dihydroartemisinin-piperaquine (DP) for post-discharge malaria chemoprevention (PDMC) among children who have been treated for severe anaemia and severe malaria. The policy for treating uncomplicated malaria has changed over the years due to drug resistance. Until 2000, MOH recommended Chloroquine (CQ) as the first-line therapy for management of uncomplicated malaria. However, due to the increased parasitological resistance to CQ, MOH changed the policy and adopted a combination of CQ and SP (CQ/SP) as first-line treatment [ 67 ]. However, between 2001 and 2004, the efficacy of CQ/SP reduced significantly [ 68 , 69 , 70 ], and Uganda yet again changed the policy and adopted the currently recommended artemisinin combination therapies (ACTs) as the first-line treatment for uncomplicated malaria. Quinine was selected as the second-line treatment for uncomplicated malaria and first-line treatment for severe malaria. The MOH policy for case management for uncomplicated malaria among pregnant women recommends that women in the first trimester should be treated with oral quinine [ 13 , 47 ], and ACTs during the second and third trimesters [ 47 ]. Discussion This scoping review found that Uganda has had varying success in achieving targets for several malaria indicators over the past two and half decades. The knowledge about the different aspects of malaria prevention and control including health-seeking behaviour have significantly improved. Significant progress has also been achieved on major prevention methods specifically ownership and use of LLINs. Case management and the use of diagnostic testing have remarkably progressed. Targeted interventions specifically IRS and SMC have shown great potential in areas of high transmission. Progress on IPTp uptake and IRS has been relatively slow and has consistently been below national targets. Other integrated vector management strategies such as larviciding and environmental management have been hardly exploited by the NMCP. CHWs are currently an underutilized resource in the prevention and control of malaria in the community. These findings suggest that national efforts and resources have focused on promoting certain interventions such as LLINs and case management. However, efforts to increase uptake of underutilised interventions are needed as the country targets malaria elimination. Uganda has made remarkable progress in the efforts to prevent and control malaria as evidenced by the improvement in knowledge, attitudes and practices in recent years. Improvements in knowledge on malaria prevention and control have also been registered in other malaria endemic countries such as Ethiopia [ 71 ], Zambia [ 72 ], and Zimbabwe [ 73 ]. The LLIN coverage in Uganda was most recently estimated at 83% in 2019 [ 12 ], which was much higher than the average LLIN coverage in sub-Saharan Africa in the same year (67%) [ 74 ]. Achievements in LLIN use in Uganda and sub-Saharan Africa is largely attributed to the increased global expenditure on malaria prevention and control between 2004 and 2015 [ 74 ]. Following increased household LLIN coverage, Uganda has currently shifted its focus from having at least one LLIN per household to the ambitious target of achieving universal LLIN coverage for all Ugandans [ 5 ]. However, although evidence has supported universal coverage in preventing malaria in highly endemic countries [ 75 ], recent studies from various African countries have shown contrasting results. For example, malaria among children in Burkina Faso increased shortly after the mass distribution of LLINs in efforts to achieve LLIN universal coverage [ 76 ]. Similarly, mass distribution of LLINs was not associated with reduced incidence of malaria in Mali and Zambia [ 77 , 78 ]. This could be attributed to the low usage of the LLINs by the community, despite having them. As Uganda progresses towards malaria pre-elimination, enhanced efforts should be focused on proper and consistent utilization of the LLINs in households. Progress on IRS was initially slow, but the coverage of the intervention has substantially increased in the target areas. MOH scaled up and concentrated IRS in only selected districts which had the highest burden of malaria [ 22 ]. Similar to Uganda, most countries in sub-Saharan Africa have deployed IRS in most at risk communities [ 79 ]. Indeed, this research has found that abruptly stopping IRS in a high transmission area led to a surge in malaria cases shortly after [ 42 ]. This implies that IRS must be sustained especially in high transmission areas as countries progress towards elimination [ 61 ]. Although routine IRS may be unsustainable in low and moderate transmission settings, modifications such as targeted IRS have been found cost-effective even in low transmission settings [ 80 ]. Therefore, as Uganda and other countries progress towards malaria elimination, targeted IRS could be implemented even in low transmission settings, thus increasing the proportion of the population that is protected by the intervention. Similar to IRS, SMC is an intervention that has been piloted in high malaria transmission areas, specifically Northeastern Uganda. SMC has delivered promising results in the implemented areas, but it is yet to be scaled to other high transmission areas. Similar results were observed in earlier studies conducted in Gambia and Burkina Faso [ 81 ]. Although the implementation of SMC has led to reduction in malaria incidence in the pilot areas, there is limited evidence about the feasibility if this intervention on a large scale. Different parameters such as quality of the drugs and limited availability of child-friendly drug options [ 82 ] may affect the effectiveness of the strategy. IPTp registered gradual but steady progress until a substantial increase was recorded in 2019 (72%). The possible reason for the initial slow uptake of IPTp in Uganda is that most women did not understand its benefits, and many were afraid of the side effects of SP / Fansidar [ 29 ]. Indeed, the recent substantial increase in IPTp uptake is in line with the recent improvement in knowledge on the practice across the country. Other reasons for the initial low uptake of IPTp were antenatal care (ANC) clinics being far, and long waiting times at health facilities [ 22 , 34 ]. Similar challenges attributed to low uptake of IPTp have been documented in other African countries such as Ghana [ 83 ] and Mozambique [ 84 ]. These health systems challenges to health seeking practices particularly low attendance of ANC need to be addressed by MOH and other stakeholders to increase uptake of IPTp as a key malaria control intervention among pregnant women. Like many other developing countries [ 85 ], LSM is currently an underutilized IVM strategy in Uganda. This may be attributed to the lack of a country-specific framework to guide implementation and scaling of the strategy [ 86 ]. Indeed, progress on malaria control has stalled, highlighting the need to redefine the IVM strategy and bring on board new approaches and innovations such as LSM for impact [ 87 ]. Indeed, if such non-conventional strategies for malaria control are embraced particularly in highly endemic areas, Uganda’s progress toward pre-elimination of the disease could be enhanced. This review established that the implementation of malaria diagnostic testing and treatment has improved since 2005. The adoption of RDTs marked a significant increase in the diagnostic testing instead of symptomatic diagnosis. The global commitment to reduce the cost of RDTs gradually made symptomatic diagnosis less attractive [ 33 ]. Indeed, the increased uptake of RDTs led to a two-fold reduction in the prescription of anti-malarial medication [ 88 ] The reduction in the prescription of anti-malarial medication was also observed in other malaria endemic settings such as Zanzibar [ 89 ] and Burkina Faso and Nigeria [ 90 ]. The success in the uptake of diagnostic testing illustrates the impact of sustained national commitment and financial mechanisms in public health programming to protect against stock-outs and other challenges that affect utilization of health programmes. This review found that most CHWs were non-functional and only a small proportion of households were aware of their services. Therefore, CHWs, as well as the iCCM strategy which includes diagnosis and treatment of children with malaria, are underutilized in Uganda. The under-utilization of CHWs and iCCM has also been reported in Kenya [ 91 ] and Nigeria [ 92 ]. CHWs also often lack necessities such as medical supplies and incentives to facilitate their work, which affects their performance. Similar challenges concerning CHWs have been reported in other low- and middle-income countries such as Nigeria [ 93 ] and Mozambique [ 94 ]. Despite these challenges, the iCCM strategy has proved to be effective in bridging the gap in health care service delivery in communities where it has been implemented, especially in hard-to-reach areas [ 95 , 96 ]. Therefore, there is a need to strengthen the CHW programme and increase motivation of these volunteers through routine monetary and non-monetary incentives such as regular supervision and recognition [ 97 , 98 ]. It was established in the review that over the past two and half decades, the Government of Uganda through MOH has shown political commitment to malaria control through adopting, adapting, and updating malaria policies in line with the WHO and local context [ 4 ]. This has facilitated the implementation of various malaria prevention and control interventions such as IRS and mass distribution of LLINs. However, the current malaria prevention policies have heavily focused on LLINs and IRS while significantly ignoring other strategies such as LSM and environmental management [ 99 ]. Implementing various malaria prevention and control strategies significantly reduces the challenge of drug resistance and exploits a range of mosquito feeding and resting behaviour. Indeed, the WHO has stressed the importance of IVM if countries are to progress towards malaria elimination [ 100 ]. Therefore, low priority of some IVM interventions may have stalled the progress on reducing the malaria burden and probably elimination in Uganda. Since the reduction in malaria burden has stagnated over the past few years, it is important to refocus the political commitment and consider other IVM measures that can complement and enhance the current main malaria control strategies. To build on Uganda’s progress in malaria control, a multi-sectoral approach is recommended. The country must move beyond distribution of preventive measures for example LLINs and focus on their consistent and proper use. Successful intervention such as IRS and LSM should be sustained and expanded to all high transmission areas. A robust multi-sectoral commitment is also needed to adopt comprehensive IVM policies which embrace wider range of control measures, complementing existing strategies and adapting to the evolving challenges of drug resistance. A limitation of the study is that the findings were largely based on Malaria Indicator Surveys and Uganda Demographic and Surveys which are conducted after relatively long periods and use cross-sectional study designs hence cannot make inferences on behaviour change over time. In addition, due to the nature of the scoping review, rigorous critical appraisal of the included articles was not conducted. Nevertheless, this is one of the few scoping reviews to document Uganda’s progress on key malaria indicators over the past two decades as the country aims to progress towards malaria pre-elimination. Conclusion Uganda has registered considerable progress on malaria indicators in the past two and half decades. Knowledge and practices on major malaria prevention and control indicators have significantly improved. Interventions such as LLINs, IRS and case management have been embraced and scaled up, while others such as LSM and environmental management have been largely neglected. Uganda has adopted different malaria control policies in accordance with WHO guidelines despite challenges in some interventions such as IPTp and iCCM. Progress towards malaria pre-elimination requires a multi-sectoral approach and refocusing political commitment to currently underutilized IVM strategies. Continued engagement of communities is crucial to further bridge the existing gap between knowledge and practices on malaria control. Abbreviations ACTs: artimesinin combination therapies; CHW: Community Health Worker; CQ: Chloroquine; iCCM: Integrated Community Case Management; IRS: Indoor Residual Spraying; IPTp: Intermittent Preventive Treatment during pregnancy; IVM: Integrated Vector Management: LLINs; Long Lasting Insecticidal Nets; LSM: larval source management; MOH: Ministry of Health; NMCP: National Malaria Control Programme; SP: sulfadoxine pyrimethamine; VHT: village health team; WHO: World Health Organization Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests. Funding The study was funded by the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria through The AIDS Support Organization. Authors’ contributions DM, AY and MT conceived the study. SN conducted the initial review with the support of DM and AY. SN, DM, SN, AY and MT were involved in writing the manuscript. All authors read and approved the final manuscript. Author information 1 Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda 2 The AIDS Support Organization, Kampala, Uganda. 3 Ministry of Health, Kampala, Uganda Acknowledgements We acknowledge all partners who have supported our malaria research in Uganda in recent years including the National Malaria Control Division at Ministry of Health and various District Health Teams. References Ministry of Health. (2020). The Uganda Malaria Reduction and Elimination Strategic Plan 2021-2025. Ministry of Health. (2018). Uganda Malaria Annual Report July 2017-June 2018. Kampala, Uganda. World Health Organization. (2023). World Malaria Report/ Uganda. Available from [Accessed on 1/9/2024]. Matovu F, Nanyiti A, Rutebemberwa E. Household health care-seeking costs: experiences from a randomized, controlled trial of community-based malaria and pneumonia treatment among under-fives in eastern Uganda. Malar J. 2014 Jun 5;13:222. doi: 10.1186/1475-2875-13-222. Ministry of Health. (2014). The Uganda malaria reduction strategic plan 2014-2020. Kampala, Uganda. Available from [Accessed on 20th/09/2019]. World Bank. (2016) Uganda Poverty Assessment 2016: Fact Sheet. Available from [Accessed on 1/9/2019]. Ministry of Health. Uganda Malaria Annual Report July 2018-June 2019. Kampala, Uganda. 2019. Available from https://www.moh.gov. [Accessed 1/9/2019]. World Health Organization. World Malaria Report 2020. 20 years of Global Progress and challenges. Geneva: WHO; 2020, p.2020. Lynch C, Hewitt S. Malaria in the Asia-Pacific: burden, success and challenges. Sydney, Australia: Malaria. 2012. Malaria Consortium. Historic campaign delivers mosquito nets to every household across Uganda. Kampala: Malaria Consortium; 2014. http://www.malariaconsortium.org/news-centre/historic-campaign-delivers-mosquito-nets-to-every-household-across-uganda.htm. Accessed 19 March 2020. Ministry of Health. Launch of the LLIN Mosquito Net Campaign 2020. Kampala: Ministry of Health; 2020. https://www.health.go.ug/cause/launch-of-the-llin-mosquito-net-2020-campaign. Accessed 10 March 2020. Uganda National Malaria Control Division (NMCD), Uganda Bureau of Statistics (UBOS), and Inner City Fund (ICF). 2020. Uganda Malaria Indicator Survey 2018-19. Kampala, Uganda, and Rockville, Maryland, USA: NMCD, UBOS, and ICF. Available from: https://dhsprogram.com/publications/publication-MIS34-MIS-Final-Reports.cfm. Accessed 1/11/2021. U.S. President’s Malaria Initiative Uganda Malaria Operational Plan FY 2023. Retrieved from www.pmi.gov Ministry of Health. Health Sector Strategic Plan III 2010/11-2014/15. 2010. Available from https://health.go.ug/docs/HSSP_III_2010.pdf. Accessed on 15/11/2021. Musoke D, Namata C, Ndejjo R, Ssempebwa JC, Musoke MB. Integrated malaria prevention in rural communities in Uganda: a qualitative feasibility study for a randomised controlled trial. Pilot Feasibility Stud. 2021;7(1):155. doi: 10.1186/s40814-021-00894-0. Adams J, Hillier-Brown FC, Moore HJ, Lake AA, Araujo-Soares V, White M, et al. Searching and synthesising ‘grey literature’ and ‘grey information’ in public health: critical reflections on three case studies. Syst Rev. 2016;5:164. McGowan J, Sampson M, Lefebvre C. An evidence based check-list for the peer review of electronic search strategies (PRESS EBC). Evid Based Lib and Info Pract. 2010;5:149-54. Joanna Briggs Institute. Joanna Briggs Institute reviewers’ manual: 2014 edition. Australia: The Joanna Briggs Institute . 2014. ATLAS.ti Scientific Software Development GmbH. Available from www.atlas-ti.com Kastner M, Tricco AC, Soobiah C, Lillie E, Perrier L, Horsley T, et al. What is the most appropriate knowledge synthesis method to conduct a review? Protocol for a scoping review. BMC Med Res Methodol. 2012;12(1):1-0. Peters, M.D., Godfrey, C.M., Khalil, H., McInerney, P., Parker, D. and Soares, C.B. Guidance for conducting systematic scoping reviews.Int J Evid Based Healthc, 2015, 13(3), pp.141-146. Uganda Bureau of Statistics (UBOS) and ICF International. Uganda Malaria Indicator Survey 2014-15. Kampala, Uganda, and Rockville, Maryland, USA: UBOS and ICF International. 2015 Uganda Bureau of Statistics (UBOS) and ICF Macro. Uganda Malaria Indicator Survey 2009. Calverton, Maryland, USA: UBOS and ICF Macro. 2010 Rek J, Musiime A, Zedi M, Otto G, Kyagamba P, Asiimwe Rwatooro J, Arinaitwe E, Nankabirwa J, Staedke SG, Drakeley C, Rosenthal PJ. Non-adherence to long-lasting insecticide treated bednet use following successful malaria control in Tororo, Uganda. PloS One; 2020; 15(12):e0243303. Kiggundu VL., O'Meara WP., Musoke R., Nalugoda, FK., Kigozi G., Baghendaghe E., Lutalo T., Achienge MK., Reynolds SJ., Makumbi F. and Serwadda D. (2013). High prevalence of malaria parasitemia and anemia among hospitalized children in Rakai, Uganda. PLoS One, 8 (12), p.e82455. Lindblade KA, O'neill DB, Mathanga DP, Katungu J, Wilson ML. Treatment for clinical malaria is sought promptly during an epidemic in a highland region of Uganda. Trop Med Int Health. 2008; 5(12): 865-875. Ndyomugyenyi R, Magnussen P, Clarke S. Malaria treatment-seeking behaviour and drug prescription practices in an area of low transmission in Uganda: implications for prevention and control. Trans R Soc Trop Med Hyg. 2007;101(3):209-15. Mbonye AK, Mohamud SM, Bagonza J. Perceptions and practices for preventing malaria in pregnancy in a peri-urban setting in south-western Uganda. Malaria Journal. 2016 Dec;15(1):1-5. Mbonye AK, Neema S, Magnussen P. Treatment-seeking practices for malaria in pregnancy among rural women in Mukono district, Uganda. J Biosoc Sci. 2006;38(2):221-37.. Musoke D, Karani G, Morris K, Ndejjo R, Atusingwize E, Guwatudde D, Musoke MB. Integrated approach to malaria prevention at household level in rural communities in Wakiso district, Uganda: impact evaluation of a pilot project. Afr Health Sci. 2018 Dec;18(4):1144-1156. Wanzira H, Katamba H, Rubahika D. Use of long-lasting insecticide-treated bed nets in a population with universal coverage following a mass distribution campaign in Uganda Malar J. 2016; 15:311. Berkley JA, Maitland K, Mwangi I, Ngetsa C, Mwarumba S, Lowe BS, Newton CR, Marsh K, Scott JA, English M. Use of clinical syndromes to target antibiotic prescribing in seriously ill children in malaria endemic area: observational study. BMJ. 2005 Apr 30;330(7498):995. doi: 10.1136/bmj.38408.471991.8F. Epub 2005 Mar 29. PMID: 15797893; PMCID: PMC557145. Batwala V, Magnussen P, Hansen KS, Nuwaha F. Cost-effectiveness of malaria microscopy and rapid diagnostic tests versus presumptive diagnosis: implications for malaria control in Uganda. Malar J. 2011 Dec 19;10:372. doi: 10.1186/1475-2875-10-372. PMID: 22182735; PMCID: PMC3266346. Bawate C, Callender-Carter ST, Nsajju B, Bwayo D. Factors affecting adherence to national malaria treatment guidelines in management of malaria among public healthcare workers in Kamuli District, Uganda. Malar J. 2016;15:112. Ministry of Health. Monitoring and evaluation plan for Uganda malaria reduction strategic plan, Kampala; 2014. Kigozi RN, Bwanika J, Goodwin E, Thomas P, Bukoma P, Nabyonga P, Isabirye F, Oboth P, Kyozira C, Niang M, Belay K, Sebikaari G, Tibenderana JK, Gudoi SS. Determinants of malaria testing at health facilities: the case of Uganda. Malar J. 2021 Dec 4;20(1):456. doi: 10.1186/s12936-021-03992-9. PMID: 34863172; PMCID: PMC8645102. Uganda Ministry of Health, National Malaria Control Division, Surveillance Monitoring & Evaluation Unit. 2019. National Malaria Annual Report 2017-2018, Kampala, Uganda https://health.go.ug/publications. Uganda Ministry of Health, National Malaria Control Division, Surveillance Monitoring & Evaluation Unit. 2022. National Malaria Annual Report 2021-2022, Kampala, Uganda https://health.go.ug/publications Staedke SG, Mpimbaza A, Kamya MR, Nzarubara BK, Dorsey G, Rosenthal PJ. Combination treatments for uncomplicated falciparum malaria in Kampala, Uganda: randomised clinical trial. The Lancet. 2004 Nov 27;364(9449):1950-7. Yeka A, Banek K, Bakyaita N, Staedke SG, Kamya MR, Talisuna A, Kironde F, Nsobya SL, Kilian A, Slater M, Reingold A, Rosenthal PJ, Wabwire-Mangen F, Dorsey G. Artemisinin versus nonartemisinin combination therapy for uncomplicated malaria: randomized clinical trials from four sites in Uganda. PLoS Med. 2005 Jul;2(7):e190. doi: 10.1371/journal.pmed.0020190. Epub 2005 Jul 26. PMID: 16033307; PMCID: PMC1181876. Ministry of Health, Uganda, National policy on malaria treatment 2005, 2005, http://www.health.go.ug/mcp/NationalPolicy World Health Organization, Position of WHO′s Roll Back Malaria Department on malaria treatment policy, 2003, http://www.who.int/malaria/publications/ato Kibira, D., Ssebagereka, A., van den Ham, H.A., Opigo, J., Katamba, H., Seru, M., Reed, T., Leufkens, H.G. and Mantel-Teeuwisse, A.K., 2021. Trends in access to anti‐malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first‐line anti‐malarials and diagnostics between 2007 and 2018. Malaria Journal, 20, pp.1-8. Kwiringira A, Nanziri C, Nsubuga EJ, Migamba SM, Ntono V, Atuhaire I, Ahirirwe SR, Asio A, Senyange S, Nakamya P, Masanja V, Elayeete S, Komakech A, Nansikombi HT, Mwine P, Nampeera R, Ndyabakira A, Okello P, Migisha R, Bulage L, Kwesiga B, Kadobera D, Rutazaana D, Harris JR, Ario AR. Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021. Malar J. 2022 Dec 3;21(1):367. doi: 10.1186/s12936-022-04401-5. PMID: 36463150; PMCID: PMC9719168. Uganda Bureau of Statistics (UBOS) and ICF International Inc. Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc. 2012. Uganda Bureau of Statistics. Uganda National Household Survey 2005/6. Kampala, Uganda. 2006 Uganda Bureau of Statistcs (UBOS) and ICF International. Uganda Demographic and Health Survey 2016: Key Indicators Report. Kampala, Uganda: UBOS, and Rockville, Maryland, USA: UBOS and ICF International. 2018. ter Kuile FO, van Eijk AM, Filler SJ. Effect of sulfadoxine-pyrimethamine resistance on the efficacy of intermittent preventive therapy for malaria control during pregnancy: a systematic review. JAMA. 2007;297(23): 2603-2616. Ameyaw EK. Uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in Uganda: a national survey. Malar J. 2022 Oct 7;21(1):285. doi: 10.1186/s12936-022-04299-z. PMID: 36207727; PMCID: PMC9547429. Raouf S, Mpimbaza A, Kigozi R, Sserwanga A, Rubahika D, Katamba H, et al. Resurgence of Malaria Following Discontinuation of Indoor Residual Spraying of Insecticide in an Area of Uganda With Previously High-Transmission Intensity. Clin Infect Dis. 2017;65(3):453–60. pmid:28369387; PubMed Central PMCID: PMC5850037. World Health Organization. Compendium of WHO malaria guidance: prevention, diagnosis, treatment, surveillance and elimination. World Health Organization; 2019. Uganda Bureau of Statistics.Uganda National Household Survey 2001/2. Kampala, Uganda. 2002. Tukei BB, Beke A, Lamadrid-Figueroa H. Assessing the effect of indoor residual spraying (IRS) on malaria morbidity in Northern Uganda: a before and after study. Malar J. 2017;16(1):4. Kigozi R, Baxi SM., Gasasira A, Sserwanga A, Kakeeto S, Nasr S, Rubahika D, Dissanayake G, Kamya M. R., Filler S, Dorsey G. Indoor Residual Spraying of Insecticide and Malaria Morbidity in a High Transmission Intensity Area of Uganda. PLoS One. 2012;7: e42857. Simple O, Mindra A, Obai G, Ovuga E, Odongo-Aginya EI. Influence of Climatic Factors on Malaria Epidemic in Gulu District, Northern Uganda: A 10-Year Retrospective Study. Malar Res Treat. 2018 Aug 13;2018:5482136. Musoke D, Nyashanu M, Bugembe H, Lubega GB, O'Donovan J, Halage AA, Gibson L. Contested notions of challenges affecting Community Health Workers in low- and middle-income countries informed by the Silences Framework. Hum Resour Health. 2022 Jan 6;20(1):4. doi: 10.1186/s12960-021-00701-0. PMID: 34991590; PMCID: PMC8734299. Awor P, Kalyango JN, Stålsby Lundborg C, Ssengooba F, Eriksen J, Rutebemberwa E. Policy Challenges Facing the Scale Up of Integrated Community Case Management (iCCM) in Uganda. Int J Health Policy Manag. 2022 Aug 1;11(8):1432-1441. doi: 10.34172/ijhpm.2021.39. Epub 2021 May 24. PMID: 34124867; PMCID: PMC9808347. Musoke D, Ndejjo R, Atusingwize E, Ssemugabo C, Ottosson A, Gibson L, Waiswa P. Panacea or pitfall? The introduction of community health extension workers in Uganda. BMJ Glob Health. 2020 Aug;5(8):e002445. doi: 10.1136/bmjgh-2020-002445. PMID: 32816827; PMCID: PMC7430324. O'Donovan J, Stiles CE, Sekimpi D, Ddumba I, Winters N, O'Neil E Jr. Potential challenges of implementing the Community Health Extension Worker programme in Uganda. BMJ Glob Health. 2018 Aug 10;3(4):e000960. doi: 10.1136/bmjgh-2018-000960. PMID: 30116596; PMCID: PMC6089279. Kaufman MR, Rweyemamu D, Koenker H, Macha J (2012). "My children and I will no longer suffer from malaria": a qualitative study of the acceptance and rejection of indoor residual spraying to prevent malaria in Tanzania. Malar J. 2012; 11: 220. WHO. Policy recommendation: seasonal malaria chemoprevention (SMC) for Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa. Geneva: World Health Organization; 2012. Nakkazi E. Karamojong people embrace malaria chemoprevention. Lancet Infect Dis. 2021 Nov;21(11):1499. doi: 10.1016/S1473-3099(21)00636-8. PMID: 34717809. Kigozi SP, Kigozi RN, Sebuguzi CM, Cano J, Rutazaana D, Opigo J, Bousema T, Yeka A, Gasasira A, Sartorius B, Pullan RL. Spatial-temporal patterns of malaria incidence in Uganda using HMIS data from 2015 to 2019. BMC Public Health. 2020 Dec 14;20(1):1913. doi: 10.1186/s12889-020-10007-w. PMID: 33317487; PMCID: PMC7737387. Wennström P. Cattle, conflict, and climate variability: explaining pastoralist conflict intensity in the Karamoja region of Uganda. Regional Environ Change. 2024;24:54. Kwiringira A, Kwesiga B, Migisha R, Bulage L, Kadobera D, Rutazaana D, Harris JR, Ario AR, Ssempiira J. Effect of seasonal malaria chemoprevention on incidence of malaria among children under five years in Kotido and Moroto Districts, Uganda, 2021: time series analysis. Malar J. 2024 Dec 18;23(1):389. doi: 10.1186/s12936-024-05220-6. PMID: 39695723; PMCID: PMC11657844. Nuwa A, Baker K, Kajubi R, Nnaji CA, Theiss-Nyland K, Odongo M, Kyagulanyi T, Nabakooza J, Salandini D, Asua V, Nakirunda M. Effectiveness of sulfadoxine–pyrimethamine plus amodiaquine and dihydroartemisinin–piperaquine for seasonal malaria chemoprevention in Uganda: a three-arm, open-label, non-inferiority and superiority, cluster-randomised, controlled trial. The Lancet Infectious Diseases. 2025 Jan 15. Kamya MR, Bakyaita NN, Talisuna AO, Were WM, Staedke SG. Increasing antimalarial drug resistance in Uganda and revision of the national drug policy. Trop Med Int Health. 2002;7(12):1031-41. World Health Organization. (2010) Global report on antimalarial drug efficacy and drug resistance: 2000–2010. Available from: http://www.searo.who.int/LinkFiles/Malaria_antimalarial_drug_efficacy10.pdf. Accessed on 29/8/2019. Talisuna AO, Nalunkuma-Kazibwe A, Bakyaita N, Langi P, Mutabingwa TK, Watkins WW, et al. Efficacy of sulphadoxine-pyrimethamine alone or combined with amodiaquine or chloroquine for the treatment of uncomplicated falciparum malaria in Ugandan children. Trop Med Int Health. 2004;9(2):222-9. Bakyaita N, Dorsey G, Yeka A, Banek K, Staedke SG, Kamya MR. et al. Sulfadoxine-pyrimethamine plus chloroquine or amodiaquine for uncomplicated falciparum malaria: a randomized, multisite trial to guide national policy in Uganda. Am J Trop Med Hyg. 2005;72(5):573-580. Jima D, Getachew A, Bilak H, Steketee RW, Emerson PM, Graves PM, et al. Ethiopia Malaria Indicator Survey Working Group. Malaria indicator survey 2007, Ethiopia: coverage and use of major malaria prevention and control interventions. Malar J. 2010;9:58. Chizema-Kawesha E, Miller JM, Steketee RW, Mukonka VM, Mukuka C, Mohamed AD, et al. Scaling up malaria control in Zambia: progress and impact 2005-2008. Am J Trop Med Hyg. 2010;83(3):480-8. Sande S, Zimba M, Mberikunashe J, Tangwena A, Chimusoro A. Progress towards malaria elimination in Zimbabwe with special reference to the period 2003-2015. Malar J. 2017;16(1):295. Cibulskis RE, Alonso P, Aponte J, Aregawi M, Barrette A, Bergeron L, et al. Malaria: Global progress 2000 - 2015 and future challenges. Infect Dis Poverty. 2016;5(1):61. Killeen GF. Control of malaria vectors and management of insecticide resistance through universal coverage with next-generation insecticide-treated nets. The Lancet. 2020 Apr 25;395(10233):1394-400. Louis VR, Schoeps A, Tiendrebéogo J, Beiersmann C, Yé M, Damiba MR, Lu GY, Mbayiha AH, De Allegri M, Jahn A, Sié A, Becher H, Müller O. An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso. Bull World Health Organ. 2015;93(11):750-8. Coulibaly D, Travassos MA, Kone AK, Tolo Y, Laurens MB, Traore K, et al. Stable malaria incidence despite scaling up control strategies in a malaria vaccine-testing site in Mali. Malar J. 2014;13:374. Mukonka VM, Chanda E, Haque U, Kamuliwo M, Mushinge G, Chileshe J, et al. High burden of malaria following scale-up of control interventions in Nchelenge District, Luapula Province, Zambia. Malar J. 2014;13:153. Tangena JA, Hendriks CMJ, Devine M, Tammaro M, Trett AE, Williams I, et al. Indoor residual spraying for malaria control in sub-Saharan Africa 1997 to 2017: an adjusted retrospective analysis. Malar J. 2020;19(1):150. doi: 10.1186/s12936-020-03216-6. Bath D, Cook J, Govere J, Mathebula P, Morris N, Hlongwana K, Raman J, Seocharan I, Zitha A, Zitha M, Mabuza A. Effectiveness and cost-effectiveness of reactive, targeted indoor residual spraying for malaria control in low-transmission settings: a cluster-randomised, non-inferiority trial in South Africa. The Lancet. 2021 Feb 27;397(10276):816-27. Oppong FB, Gyaase S, Zandoh C, Nettey OEA, Amenga-Etego S, Anane EA, et al. Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015. BMJ Open. 2019;9(6):e027946. doi: 10.1136/bmjopen-2018-027946. ACCESS-SMC Partnership. Effectiveness of seasonal malaria chemoprevention at scale in west and central Africa: an observational study. Lancet. 2020 Dec 5;396(10265):1829-1840. doi: 10.1016/S0140-6736(20)32227-3. PMID: 33278936; PMCID: PMC7718580 Kyabayinze DJ, Asiimwe C, Nakanjako D, Nabakooza J, Counihan H, Tibenderana JK. Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda. Malar J. 2010 Jul 12;9:200. doi: 10.1186/1475-2875-9-200. PMID: 20624312; PMCID: PMC2914063. Arnaldo P, Rovira-Vallbona E, Langa JS, Salvador C, Guetens P, Chiheb D, et al. Uptake of intermittent preventive treatment and pregnancy outcomes: health facilities and community surveys in Chókwè district, southern Mozambique. Malar J. 2018;17(1):109. doi: 10.1186/s12936-018-2255-z. Chanda E, Mzilahowa T, Chipwanya J, Ali D, Troell P, Dodoli W, et al. Scale-up of integrated malaria vector control: lessons from Malawi. Bull World Health Organ. 2016;94(6):475-80. doi: 10.2471/BLT.15.154245. Mutero CM, Schlodder D, Kabatereine N, Kramer R. Integrated vector management for malaria control in Uganda: knowledge, perceptions and policy development. Malar J. 2012;11:21. doi: 10.1186/1475-2875-11-21. Townson H, Nathan MB, Zaim M, Guillet P, Manga L, Bos R, Kindhauser M. Exploiting the potential of vector control for disease prevention. Bull World Health Organ. 2005 Dec;83(12):942-7. Kisia J, Nelima F, Otieno DO, Kiilu K, Emmanuel W, Sohani S, Siekmans K, Nyandigisi A, Akhwale W. Factors associated with utilization of community health workers in improving access to malaria treatment among children in Kenya. Malar J. 2012;11:248. doi: 10.1186/1475-2875-11-248. Msellem MI, Mårtensson A, Rotllant G, Bhattarai A, Strömberg J, Kahigwa E, Garcia M, Petzold M, Olumese P, Ali A, Björkman A. Influence of rapid malaria diagnostic tests on treatment and health outcome in fever patients, Zanzibar: a crossover validation study. PLoS Med. 2009 Apr 28;6(4):e1000070. doi: 10.1371/journal.pmed.1000070. Epub 2009 Apr 28. PMID: 19399156; PMCID: PMC2667629. Ajayi IO, Nsungwa-Sabiiti J, Siribié M, Falade CO, Sermé L, Balyeku A, Afonne C, Sanou AK, Kabarungi V, Oshiname FO, Gansane Z, Kyaligonza J, Jegede AS, Tiono AB, Sirima SB, Diarra A, Yusuf OB, Fouque F, Castellani J, Petzold M, Singlovic J, Gomes M. Feasibility of Malaria Diagnosis and Management in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study. Clin Infect Dis. 2016 Dec 15;63(suppl 5):S245-S255. doi: 10.1093/cid/ciw622. PMID: 27941101; PMCID: PMC5146694. Pallas SW, Minhas D, Pérez-Escamilla R, Taylor L, Curry L, Bradley EH. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability? Am J Public Health. 2013;103(7):e74-82. Emukah EC, Enyinnaya U, Olaniran NS, Akpan EA, Hopkins DR, Miri ES, et al. Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria. Ann Trop Med Parasitol. 2008;102(1):45-51. Chuke NU, Okafor SO, Mbagwu FO, Ike OO, Ogbonna AN, Okoye OE. Rural Health Workers and Primary Health Care Promotion in Southeast Nigeria: Challenges and Their Implication to Community and Sustainable Development. International Journal of Sustainable Development & Planning. 2023 Jan 1;18(1). Simon S, Chu K, Frieden M, Candrinho B, Ford N, Schneider H, et al. An integrated approach of community health worker support for HIV/AIDS and TB care in Angónia district, Mozambique. BMC Int Health Hum Rights. 2009;9:13. Musoke D, Miiro G, Ndejjo, R., Karani G, Morris K, Kasasa S, et al. Malaria prevention practices and associated environmental risk factors in a rural community in Wakiso district, Uganda. PLoS One 2018;13(10): e0205210. Kalyango JN, Rutebemberwa E, Alfven T, Ssali S, Peterson S, Karamagi C. Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda. Malar J. 2012;11:282. Chipukuma HM, Zulu JM, Jacobs C, Chongwe G, Chola M, Halwiindi H,et al. Towards a framework for analyzing determinants of performance of community health workers in malaria prevention and control: a systematic review. Hum Resour Health. 2018;16(1):1-6. Winn LK, Lesser A, Menya D, Baumgartner JN, Kirui JK, Saran I, et al. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health. 2018;8(1). Nalinya S, Musoke D, Deane K. Malaria prevention interventions beyond long-lasting insecticidal nets and indoor residual spraying in low- and middle-income countries: a scoping review. Malar J. 2022 Feb 2;21(1):31. doi: 10.1186/s12936-022-04052-6. World Health Organization. Handbook for integrated vector management. World Health Organization; 2012. Additional Declarations No competing interests reported. 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Uganda consistently ranks among the top five countries with the highest global malaria infection rates [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Malaria is of key public health importance because any delay in treatment can lead to serious health complications as well as death. In addition, the social and economic impact of malaria is significant, with care costs alone estimated at US\u003cspan\u003e$\u003c/span\u003e9 per person per episode [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. An average household spends approximately 3% of its monthly income to manage a malaria episode [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Other costs incurred at individual, household, community and national level include missed school and workdays [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and loss of foreign direct investment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough progress has undeniably been made in the scale-up of key technical and supportive interventions to control malaria in Uganda, there remains a significant gap in achieving universal coverage for impact [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To reduce the occurrence of malaria in the country, the Ministry of Health (MOH) through NMCP has five main intervention strategies: malaria case management; Intermittent Preventive Treatment during pregnancy (IPTp); environmental management including vector control; epidemic preparedness and response; and information, education and communication (IEC) including social mobilization [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The NMCP routinely sets targets for assessing progress on malaria indicators and preparing for the pre-elimination stages of the disease in Uganda. The current goal of the NMCP is to reduce malaria morbidity by 50% and malaria related mortality by 75% of the 2019 levels by the end of 2025 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe core interventions for attaining the NMCP goal profoundly relies on use of long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS), and case management [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. MOH regularly conducts mass distribution of LLINs mainly to households with children five years and pregnant women [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In addition, IRS has been scaled up in selected 15 high burden districts in West Nile, Northern and Eastern Uganda [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Community case management through community health workers was rolled out especially in rural areas to promptly diagnose and treat malaria in children aged under five years [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Other interventions of integrated vector management (IVM) such as environmental management, improvement of housing design, and larval source management are currently implemented on a small scale [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As Uganda moves towards malaria pre-elimination, there is a paucity of synthesized and summarized literature on the country\u0026rsquo;s 25-year progress on all the different malaria prevention and control strategies since the scaling up of major interventions in 2000. The objective of this scoping review was therefore to examine available literature on progress on malaria prevention and control in Uganda, understand the evolution of national control strategies and to map progress for various indicators. In addition, the review aimed at identifying gaps and opportunities for further malaria prevention and control in Uganda as the country moves towards the ambitious goal of elimination of malaria.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSearch strategy\u003c/h2\u003e\u003cp\u003eA comprehensive search across a range of databases, organisational websites, and conference abstract repositories was conducted. The databases searched included PubMed, The Cochrane Library, and Social Science abstracts. More studies were obtained through a manual search of references listed in the retrieved studies. The search also included grey literature to obtain information that was not present in commercial publications, and those aimed at a limited audience [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Specifically, searches were done on Google and websites of agencies that fund, implement or report about malaria in Uganda. Keywords used in the search included: malaria, \u003cem\u003ePlasmodium falciparum\u003c/em\u003e, \u003cem\u003ePlasmodium vivax\u003c/em\u003e, knowledge, attitude, practices, perception, mosquito net, bed net, insecticide treated bednets (ITNs), practice, misuse, acceptability, belief, Uganda, achievements and milestones. The search strategy included publications for a 24-year period (2000 to 2023). The search was limited to English language due to the large number of identified knowledge sources. The study team also sent out personalised requests via email to contacts in MOH and specifically the National Malaria Control Programme to provide any relevant literature. Following a predetermined inclusion criterion, three authors (SN, DM, AY) independently identified different knowledge sources such as published articles, unpublished articles, policy documents, commentaries, and reports for inclusion in the review. The identified articles were peer reviewed and approved by other authors guided by the evidence-based checklist of Peer Review of Electronic Search Strategies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The articles mainly focused on the prevalence on malaria in Uganda; knowledge, attitudes and practices of malaria prevention and control; as well as emergency planning and the policy environment surrounding malaria prevention and control in Uganda.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy selection criteria\u003c/h3\u003e\n\u003cp\u003eAll study designs, including qualitative and quantitative studies, policy guidelines, and reports were considered eligible for this scoping review. Although the scoping review was focused to include studies conducted on malaria in Uganda, international documents such as WHO and UNICEF reports were included. The selection criteria for this scoping review followed the population, concepts and context (PCC) format [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] as described below.\u003c/p\u003e\n\u003ch3\u003ePopulation (P)\u003c/h3\u003e\n\u003cp\u003eStudies which were conducted in Uganda and assessed the social and medical epidemiology of malaria were included irrespective of age, gender or any other characteristics of the study participants. Physical, ecological and conceptual populations were included in the review.\u003c/p\u003e\n\u003ch3\u003eConcepts (C)\u003c/h3\u003e\n\u003cp\u003eAll studies which explored interventions aimed at preventing or controlling malaria were included. The interventions were summarized into the following categories: (i) health promotion / education; (ii) testing and treatment; (iii) surveillance and mitigation; (iv) vector control; and (v) health policy.\u003c/p\u003e\n\u003ch3\u003eContents (C)\u003c/h3\u003e\n\u003cp\u003eThis review included published and unpublished studies, assessing interventions for malaria prevention and control, case studies, as well as policy documents relating to malaria prevention and control in Uganda.\u003c/p\u003e\u003cp\u003eThe resulting knowledge sources were from 2000 and 2023. The first search was conducted in May 2019, and updated searches were conducted in November 2019, June 2022 and later in January 2024. Information sources which mainly focused on subjects rather than malaria prevention and control in Uganda were excluded.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData extraction\u003c/h2\u003e\u003cp\u003eThe authors of this review conducted data extraction in several steps. First, three authors (SN, DM and AY) independently evaluated the article titles followed by their abstracts. They then selected full-text articles according to the selection criteria. A data extraction form was developed by the three authors. The form was then pre-tested by the authors on a sample of articles to verify its ease of use and completeness. The form was then used by one author (SN) to extract the relevant data from each included knowledge source. The extracted information was discussed by all authors, and a consensus was reached. Information collected were: first author, publication year, methods used, location and setting, size and characteristics of sample, interventions, study variables, and results or outcomes.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData synthesis\u003c/h3\u003e\n\u003cp\u003eFor the qualitative analysis, one author (SN) conducted the initial categorisation of the key components using Atlas.ti 8 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Details of the included knowledge sources were combined as a narrative by the study topic and results. The final categorisation was discussed by the entire research team [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Upon discussion of the preliminary categorization, a coding framework was developed by all the authors. Two authors (SN and DM) coded and categorised the relevant data units from the knowledge sources into sub-themes and themes using the framework developed by the team.\u003c/p\u003e\n\u003ch3\u003eReplicability of the search\u003c/h3\u003e\n\u003cp\u003eThe study team had a clear plan describing what we felt was a comprehensive and possibly replicable approach to searching for the knowledge sources used in this article. However, it is difficult to claim that this would result into replicable findings. Although future studies may be able to replicate our search methods, it is unlikely that they will obtain the same results, as would be expected when searching electronic databases [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMethodological quality appraisal\u003c/h2\u003e\u003cp\u003eThe study team did not evaluate the methodological quality or bias risk of the included knowledge sources, which is consistent with guidance on conducting scoping reviews [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe data search resulted in a total of 3,619 articles. We analysed all these articles using their titles and abstracts, and 72 information sources through reading in full. After removing duplicates and applying the PCC selection criteria, we selected 38 information sources that were included in this scoping review (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge on malaria\u003c/h2\u003e\u003cp\u003eThe level of knowledge among malaria caregivers on the different aspects of malaria such as the cause, spread, signs, symptoms, prevention and treatment of cases in Uganda was generally high and increased over the past two decades. For example, national reports indicated that knowledge of malaria spread through mosquito bites increased from 78% to 91% between 2009 and 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Several studies have also shown that knowledge on the signs and symptoms of uncomplicated malaria, such as fever and body weakness was generally high and widespread across the country [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe proportion of women who reported that a child with fever should be treated immediately increased from 67% in 2009 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] to 77% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Indicators for knowledge on malaria prevention have also significantly improved, with 94% of women being aware of malaria prevention methods in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Other studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] have also shown that knowledge on malaria prevention has improved in various parts of Uganda. On the other hand, knowledge on IPTp has had relatively slow progress over the past two decades. In 2009, the knowledge on IPTp was at 7% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which slightly increased to 9.3% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and substantially increased to 49% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePractices on malaria prevention and control\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003eMalaria testing and treatment\u003c/h2\u003e\u003cp\u003eProper and accurate malaria testing and diagnosis is essential for ensuring appropriate treatment in parasite-positive individuals. Until 2008, malaria diagnosis in most of Uganda's primary health care settings heavily relied on clinical symptoms [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], while the diagnostic laboratory infrastructure using microscopy existed only in major district, regional and national hospitals. This posed substantial challenges in effective malaria diagnosis in primary healthcare settings until the laboratory infrastructure was expanded to lower-level health centres. Laboratory infrastructure was introduced to lower-level primary healthcare settings, specifically HCIIIs and HCIVs through the Uganda National Minimum Health Care Package (UNMHCP) program in 2008 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, diagnostic testing remained very limited due to numerous factors such as shortage of trained staff and equipment. In 2009, Uganda adopted Rapid Diagnostic Tests (RDTs) to complement microscopy, following the WHO recommendation to rely on parasitic testing and move away from symptom-based malaria diagnosis [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Malaria testing among suspected cases was only at 24% in 2010 and substantially increased to 59% in 2013 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This increase correlated with the increased availability of RDTs in most primary healthcare settings. The current policy recommends parasitology testing using either microscopy or RDTs. Although the choice of the method depends on the level of the health facility and the availability of trained staff and supplies, microscopy remains the reference method for malaria diagnosis in Uganda [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The roll-out of RDTs for diagnosis of malaria under Integrated Case Management (ICCM) is being implemented [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe improvement of parasitic-based diagnosis of malaria, especially RDTs has enhanced diagnostic testing and hence boosted the rational use of ACTs. Uganda aimed, through the 5-year (2014\u0026ndash;2020) malaria reduction strategy, to have at least 75% of suspected malaria cases having parastic testing in 2019, and the target increased to 84% in 2021 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Indeed, the proportion of suspected malaria cases parasitically tested in public and private-not-for-profit health facilities increased from 59% in 2013 to 88% in 2017, and 97% in 2022 [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Testing of suspected malaria cases in private health facilities increased from 31% in 2013 to 44% in 2017 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. ICCM was used to boost malaria testing in the community. The proportion of suspected malaria cases tested in the community under iCCM increased from 80% in 2011 to 95% in 2017 but decreased to 92% in 2019 and 89% in 2022 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEffective case management, including prompt and appropriate treatment with affordable, effective, and safe antimalarials, remains a cornerstone of malaria control in Uganda. The combination of CQ and SP became the first-line regimen for uncomplicated malaria in 2001, but unsurprisingly the efficacy of this combination of sub-optimal therapies was ineffective [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In 2004 the first-line therapy was changed to ACTs, with artemether-lumefantrine (AL; Coartem) routinely available and artesunate plus amodiaquine (ASAQ) as an alternative first-line treatment [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Quinine was recommended as the second-line treatment. However, ensuring availability and proper use of ACTs at all facilities countrywide present some challenges. The main challenge for effective malaria treatment at public facilities is prolonged stock-outs of ACTs and non-compliance to treatment guidelines [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The new National Malaria Control Policy emphasises parasite-based diagnosis before treatment, change from IV quinine to IV artesunate in the treatment of severe malaria, replacing oral quinine with Dihydroartemisinin/Piperaquine (DP) as second line treatment for uncomplicated malaria and use of rectal artesunate for pre-referral treatment of severe malaria [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDuring the past years, ACTs of various forms have been available in the private sector but at prices not affordable by most of the population. A pilot project to deliver subsidized medicines in the private sector started in 2008. Between 2008 and 2018, the price of ACTs reduced from USD 8.8 to USD 1.1 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Research showed that availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities between 2007 and 2018 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This pilot, supported by MMV, demonstrated that providing subsidized ACTs through the private sector, where about 60% of patients first seek care, can lead to a significant increase in availability and uptake of effective treatment. Evidently, the 2009 UMIS reported that among children under five years with fever, 60% took an anti-malarial drug, and of these, 23% took an ACTs. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. ACTs use continually improved and by 2014, about 87% of children under five years with fever in the last two weeks preceding the survey, took an ACT [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The programme continued to register an improvement in the proportion of confirmed malaria cases that received ACTs at health facility level. In 2022, 99% of the patients attending health facilities with malaria received ACTs. The proportion of confirmed malaria cases that received ACTs in the community increased to 90% by 2022.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLong lasting insecticidal nets (LLINs)\u003c/h2\u003e\u003cp\u003eUse of ITNs is a cornerstone of the NMCP\u0026rsquo;s malaria control strategy in Uganda. The NMCP has pursued multiple strategies to increase ownership and use of nets, including free distribution to pregnant women through antenatal care visits, provision of subsidized ITNs through the private sector, sale of full-cost ITNs in the commercial sector and free mass distribution campaigns to achieve 100% coverage of all households (having one net per two people). The NCMP supports a public/private mix approach using all available mechanisms for distribution, sales and promotion of LLINs, including free LLIN distribution to households by mass campaign at intervals of three years, replacements of LLINs through ANC and Expanded Program on Immunizations (EPI) outlets, subsidized sales mainly through civil society and commercial sales through the private sector.\u003c/p\u003e\u003cp\u003eMOH had targets to achieve LLIN access of 85% in 2014 and 2017, and 100% in 2021 through LLIN mass distribution campaigns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Although LLIN coverage registered was slightly below target following two of the three campaigns, Uganda generally registered a remarkable increase in ownership of at least one LLIN per household, from 13% in 2001 to 90% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], 83% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and then 95% in 2021 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, although 90% of households in Uganda owned at least one LLIN in 2015, about 69% of households used them [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and this dropped to 59% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and then back to 69% in 2021 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The Government of Uganda also aimed at universal LLIN coverage, where every household owned at least one LLIN for every two people. In 2011, only 28% of households had attained universal LLIN coverage [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], which increased to 62% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and declined to 54% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A study in central Uganda showed that LLIN use among households that had achieved universal LLIN coverage was 80% [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], but there was limited literature for other regions of the country.\u003c/p\u003e\u003cp\u003eUganda has registered remarkable progress in use of LLINs among children under five years and pregnant women in the past two decades. These significant increases have largely been due to the MOH initiative to distribute free LLINs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The number of children under five years who slept under a LLIN significantly increased from 8% in 2001 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] to 75% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] but reduced to 64% in 2016 and 60% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. LLIN use among pregnant women steadily increased since 2006 from 10% [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] to 75% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, this dropped to 64% in 2016 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and 65% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eIntermittent Preventive Treatment in Pregnancy (IPTp)\u003c/h2\u003e\u003cp\u003eThe IPTp strategy has proved to be effective in preventing parasitaemia and anaemia in mothers, and in increasing birth weight thus boosting chances of survival for newborns and mothers [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In the past 15 years, MOH scaled-up IPTp using sulfadoxine-pyrimethamine (SP) / Fansidar as an important component of the malaria control programme [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The current national guidelines recommend at least four ANC visits for all pregnant mothers [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], during which they take SP / Fansidar at each of the visits [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For the delivery of IPTp, the policy recommends that pregnant women receive SP given monthly, starting from from 13 weeks till delivery. Progress in the recommended uptake of IPTp has been considerably slow but steadily improving [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In 2006, IPTp uptake (at least two doses of SP / Fansidar) was at 16% [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], which increased to 27% in 2011 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], 45% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and 72% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Availability of SP improved significantly from 8% to 80% in 2019 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Uptake of at least three doses of IPTp increased from 45% in March 2020 [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] to 60% in September 2022 meeting the target of 58% by 2021/2022. This positive trajectory shows that the targets in the remaining period of the strategic plan are likely to be achieved [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eIndoor Residual Spraying (IRS)\u003c/h2\u003e\u003cp\u003eThe NMCP strategy for IRS, has emphasized implementation in epidemic-prone areas, high transmission settings, and high-risk situations. Most recently, attention has moved from epidemic-prone areas to those with very high transmission intensity in northern Uganda [50 Raouf et al., 2017]. Mass IRS campaigns have been in place since 2006 especially in Northern Uganda which has the highest burden of the disease [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In 2009, IRS was mainly scaled up and concentrated in 10 districts in Northern Uganda [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], and later to 14 high malaria burden districts in Eastern and Central Uganda [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. MOH has updated the IRS target districts to 50 but the programme has been implemented in only 15 due to funding constraints [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2009, 32% of households in the scaled-up districts had undergone IRS, and this increased to 66% in 2011 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In 2015, 75% of households in the districts where IRS had been scaled up had undergone IRS [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. MOH had a target to conduct IRS in 30% of households in Uganda by 2018 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, this target was not achieved since only 17% of the households underwent IRS in 2017/2018 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the proportion further declined to 10% in 2018/2019. Community acceptance of IRS has been impeded by various factors including insecticide smell, cost of the insecticide, perceived ineffectiveness, environmental concerns, and side effects [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn 2020, IRS was conducted across 16 districts in the regions of Bukedi and Mid-Northern Uganda. In 2022, IRS was expanded to 9 districts in West Nile. In 2022, a total of 23 districts received IRS, protecting a population of 15.2%, short of the NSP target of 18.6% [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In 2022, the country experienced a malaria epidemic involving up to 75 districts at the peak of the epidemic. The affected districts included 10 districts (Budaka, Bugiri, Butaleja, Butebo, Kibuku, Namutumba, Pallisa, Tororo, Lira, and Serere ) that deployment a new IRS chemical clothianidin in 2020\u0026ndash;2022. Wall bioassays later showed that clothianidin remained efficacious for only 4\u0026ndash;6 months depending on the wall surface and yet IRS spraying was done once a year. The IRS chemical was accordingly switched to Actellic 300 CS in alignment with the National Insecticide Resistance Management Plan. Research has also shown that stopping IRS in areas where it had been previously implemented led to significant surge in malaria cases [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. For example, the incidence of malaria in Gulu doubled in 2015 after IRS had been stopped in the district in 2014 [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eIntegrated Community Case Management\u003c/h2\u003e\u003cp\u003eThe Health Sector Strategic Plan 2011\u0026ndash;2020 (HSSP) adopted Community Health Workers (CHWs), locally referred to as Village Health Teams (VHTs), to promote the health and well-being among the community in Uganda and bridge the gap in health service provision [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The goal of this ICCM strategy is to reduce childhood morbidity and especially mortality by providing case management for malaria, pneumonia and diarrhoea to sick children within their communities as well as identifying and referring sick newborn babies.\u003c/p\u003e\u003cp\u003eThe iCCM strategy was originally concentrated in rural areas but the Uganda Malaria Strategic Plan 2021\u0026ndash;2025 aimed to scale-up the intervention to all parts of the country including peri-urban areas. This was premised on increasing access to malaria treatment for hard-to-reach areas and key populations such as refugees and schools [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2009, only 18% of households reported knowledge on the existence of a VHT in their community [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which doubled to 37% in 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and increased to 54.5% in 2019 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The proportion of children aged 2 months \u0026minus;\u0026thinsp;5 years, presenting with a fever who were seen by VHTs and treated within 24 hours improved from 46% in 2020 to 60% in 2022 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Within ICCM supported districts, there has been a gradual reduction in morbidity and mortality, between 2019/2020 and 2021/2022, inpatient admissions for children under 5-years decreased by 9% from 189,038 to 171,948 and deaths decreased by 35% from 1333 to 866 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. There are however challenges with the iCCM strategy including high workload, religious and cultural practices [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], interruption in the supply of commodities, low motivation of VHTs, low reporting, and limited integration with other diseases programmes at the community level [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn 2018, Uganda redesigned the VHT strategy by establishing a Community Health Extension Workers (CHEWs) programme that promised to be more functional, sustainable and responsive to health services delivery. While VHTs are operate at a village level and are volunteers, the CHEWs are intended to be based at the parish level, be trained for at least six months, supervise VHTs and receive formal pay for their work [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLarval Source Management (LSM)\u003c/h2\u003e\u003cp\u003eLSM involves methods of controlling larval or adult mosquitoes using biological control techniques or environmental management [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. LSM and larviciding have been implemented on only a small scale in Uganda but the MoH plans to scale-up the strategy especially in urban areas and in the cattle corridor, as these are amenable to the sufficient entomological and geospatial surveillance essential for effective LSM [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eSeasonal Malaria Chemoprevention\u003c/h2\u003e\u003cp\u003eSeasonal Malaria Chemoprevention (SMC), the intermittent administration of a full course of course of anti-malarial medication to children between 3\u0026ndash;5 years during high malaria transmission seasons [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] has been piloted in Karamoja region [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. The region, located in North-Eastern Uganda has one prolonged wet season from May to September with over 60% rainfall and 60% malaria transmission [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. SMC has been implemented in the Karamoja region from 2021, and it is more appropriate than other malaria prevention and control strategies due to the cultural practices, housing conditions and the nomadic nature of the community [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. SMC is implemented by administering 8 full monthly doses of Sulfadoxine Pyrimethamine (SP) and Amodiaquine (SPAQ) during and after the wet season [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. SMC has been highly acceptable to stakeholders including; policy makers, implementers, and communities [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. SPAQ was found to be very well tolerated by children in Karamoja with no serious adverse reactions reported [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Implementation of SMC significantly reduced incidence of uncomplicated malaria among children under 5 years in Karamoja region [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePolicies and international commitments\u003c/h2\u003e\u003cp\u003eUganda has adopted, adapted and implemented different malaria prevention and control policies during the past two decades, mostly in line with WHO guidelines. Previously, the NMCP mainly focused on protecting those most vulnerable to malaria particularly children under five years and pregnant women [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Progressively, the focus has shifted towards achieving universal coverage for all interventions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. MOH had a target to achieve universal coverage for LLINs by December 2023 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] but this was still below the target [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], with most recent estimates at 54% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The MOH policy on IRS recommends that it should only be implemented as part of a long-term vector control or malaria elimination strategy but not as an epidemic control measure [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMOH currently recommends sulfadoxine pyrimethamine (SP) for IPTp, [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and every pregnant woman to receive a minimum of three doses of IPTp, with no maximum if they are at least a month apart [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, there is also a newly introduced policy on using dihydroartemisinin-piperaquine (DP) for post-discharge malaria chemoprevention (PDMC) among children who have been treated for severe anaemia and severe malaria. The policy for treating uncomplicated malaria has changed over the years due to drug resistance. Until 2000, MOH recommended Chloroquine (CQ) as the first-line therapy for management of uncomplicated malaria. However, due to the increased parasitological resistance to CQ, MOH changed the policy and adopted a combination of CQ and SP (CQ/SP) as first-line treatment [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. However, between 2001 and 2004, the efficacy of CQ/SP reduced significantly [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], and Uganda yet again changed the policy and adopted the currently recommended artemisinin combination therapies (ACTs) as the first-line treatment for uncomplicated malaria. Quinine was selected as the second-line treatment for uncomplicated malaria and first-line treatment for severe malaria. The MOH policy for case management for uncomplicated malaria among pregnant women recommends that women in the first trimester should be treated with oral quinine [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], and ACTs during the second and third trimesters [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review found that Uganda has had varying success in achieving targets for several malaria indicators over the past two and half decades. The knowledge about the different aspects of malaria prevention and control including health-seeking behaviour have significantly improved. Significant progress has also been achieved on major prevention methods specifically ownership and use of LLINs. Case management and the use of diagnostic testing have remarkably progressed. Targeted interventions specifically IRS and SMC have shown great potential in areas of high transmission. Progress on IPTp uptake and IRS has been relatively slow and has consistently been below national targets. Other integrated vector management strategies such as larviciding and environmental management have been hardly exploited by the NMCP. CHWs are currently an underutilized resource in the prevention and control of malaria in the community. These findings suggest that national efforts and resources have focused on promoting certain interventions such as LLINs and case management. However, efforts to increase uptake of underutilised interventions are needed as the country targets malaria elimination.\u003c/p\u003e\u003cp\u003eUganda has made remarkable progress in the efforts to prevent and control malaria as evidenced by the improvement in knowledge, attitudes and practices in recent years. Improvements in knowledge on malaria prevention and control have also been registered in other malaria endemic countries such as Ethiopia [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e], Zambia [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e], and Zimbabwe [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. The LLIN coverage in Uganda was most recently estimated at 83% in 2019 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], which was much higher than the average LLIN coverage in sub-Saharan Africa in the same year (67%) [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Achievements in LLIN use in Uganda and sub-Saharan Africa is largely attributed to the increased global expenditure on malaria prevention and control between 2004 and 2015 [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Following increased household LLIN coverage, Uganda has currently shifted its focus from having at least one LLIN per household to the ambitious target of achieving universal LLIN coverage for all Ugandans [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, although evidence has supported universal coverage in preventing malaria in highly endemic countries [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e], recent studies from various African countries have shown contrasting results. For example, malaria among children in Burkina Faso increased shortly after the mass distribution of LLINs in efforts to achieve LLIN universal coverage [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. Similarly, mass distribution of LLINs was not associated with reduced incidence of malaria in Mali and Zambia [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. This could be attributed to the low usage of the LLINs by the community, despite having them. As Uganda progresses towards malaria pre-elimination, enhanced efforts should be focused on proper and consistent utilization of the LLINs in households.\u003c/p\u003e\u003cp\u003eProgress on IRS was initially slow, but the coverage of the intervention has substantially increased in the target areas. MOH scaled up and concentrated IRS in only selected districts which had the highest burden of malaria [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similar to Uganda, most countries in sub-Saharan Africa have deployed IRS in most at risk communities [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. Indeed, this research has found that abruptly stopping IRS in a high transmission area led to a surge in malaria cases shortly after [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This implies that IRS must be sustained especially in high transmission areas as countries progress towards elimination [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Although routine IRS may be unsustainable in low and moderate transmission settings, modifications such as targeted IRS have been found cost-effective even in low transmission settings [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Therefore, as Uganda and other countries progress towards malaria elimination, targeted IRS could be implemented even in low transmission settings, thus increasing the proportion of the population that is protected by the intervention.\u003c/p\u003e\u003cp\u003eSimilar to IRS, SMC is an intervention that has been piloted in high malaria transmission areas, specifically Northeastern Uganda. SMC has delivered promising results in the implemented areas, but it is yet to be scaled to other high transmission areas. Similar results were observed in earlier studies conducted in Gambia and Burkina Faso [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. Although the implementation of SMC has led to reduction in malaria incidence in the pilot areas, there is limited evidence about the feasibility if this intervention on a large scale. Different parameters such as quality of the drugs and limited availability of child-friendly drug options [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e] may affect the effectiveness of the strategy.\u003c/p\u003e\u003cp\u003eIPTp registered gradual but steady progress until a substantial increase was recorded in 2019 (72%). The possible reason for the initial slow uptake of IPTp in Uganda is that most women did not understand its benefits, and many were afraid of the side effects of SP / Fansidar [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Indeed, the recent substantial increase in IPTp uptake is in line with the recent improvement in knowledge on the practice across the country. Other reasons for the initial low uptake of IPTp were antenatal care (ANC) clinics being far, and long waiting times at health facilities [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Similar challenges attributed to low uptake of IPTp have been documented in other African countries such as Ghana [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e] and Mozambique [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. These health systems challenges to health seeking practices particularly low attendance of ANC need to be addressed by MOH and other stakeholders to increase uptake of IPTp as a key malaria control intervention among pregnant women.\u003c/p\u003e\u003cp\u003eLike many other developing countries [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e], LSM is currently an underutilized IVM strategy in Uganda. This may be attributed to the lack of a country-specific framework to guide implementation and scaling of the strategy [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. Indeed, progress on malaria control has stalled, highlighting the need to redefine the IVM strategy and bring on board new approaches and innovations such as LSM for impact [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e]. Indeed, if such non-conventional strategies for malaria control are embraced particularly in highly endemic areas, Uganda\u0026rsquo;s progress toward pre-elimination of the disease could be enhanced.\u003c/p\u003e\u003cp\u003eThis review established that the implementation of malaria diagnostic testing and treatment has improved since 2005. The adoption of RDTs marked a significant increase in the diagnostic testing instead of symptomatic diagnosis. The global commitment to reduce the cost of RDTs gradually made symptomatic diagnosis less attractive [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Indeed, the increased uptake of RDTs led to a two-fold reduction in the prescription of anti-malarial medication [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e] The reduction in the prescription of anti-malarial medication was also observed in other malaria endemic settings such as Zanzibar [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e] and Burkina Faso and Nigeria [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]. The success in the uptake of diagnostic testing illustrates the impact of sustained national commitment and financial mechanisms in public health programming to protect against stock-outs and other challenges that affect utilization of health programmes.\u003c/p\u003e\u003cp\u003eThis review found that most CHWs were non-functional and only a small proportion of households were aware of their services. Therefore, CHWs, as well as the iCCM strategy which includes diagnosis and treatment of children with malaria, are underutilized in Uganda. The under-utilization of CHWs and iCCM has also been reported in Kenya [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e] and Nigeria [\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e]. CHWs also often lack necessities such as medical supplies and incentives to facilitate their work, which affects their performance. Similar challenges concerning CHWs have been reported in other low- and middle-income countries such as Nigeria [\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e] and Mozambique [\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e]. Despite these challenges, the iCCM strategy has proved to be effective in bridging the gap in health care service delivery in communities where it has been implemented, especially in hard-to-reach areas [\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e]. Therefore, there is a need to strengthen the CHW programme and increase motivation of these volunteers through routine monetary and non-monetary incentives such as regular supervision and recognition [\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt was established in the review that over the past two and half decades, the Government of Uganda through MOH has shown political commitment to malaria control through adopting, adapting, and updating malaria policies in line with the WHO and local context [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This has facilitated the implementation of various malaria prevention and control interventions such as IRS and mass distribution of LLINs. However, the current malaria prevention policies have heavily focused on LLINs and IRS while significantly ignoring other strategies such as LSM and environmental management [\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e]. Implementing various malaria prevention and control strategies significantly reduces the challenge of drug resistance and exploits a range of mosquito feeding and resting behaviour. Indeed, the WHO has stressed the importance of IVM if countries are to progress towards malaria elimination [\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e]. Therefore, low priority of some IVM interventions may have stalled the progress on reducing the malaria burden and probably elimination in Uganda. Since the reduction in malaria burden has stagnated over the past few years, it is important to refocus the political commitment and consider other IVM measures that can complement and enhance the current main malaria control strategies.\u003c/p\u003e\u003cp\u003eTo build on Uganda\u0026rsquo;s progress in malaria control, a multi-sectoral approach is recommended. The country must move beyond distribution of preventive measures for example LLINs and focus on their consistent and proper use. Successful intervention such as IRS and LSM should be sustained and expanded to all high transmission areas. A robust multi-sectoral commitment is also needed to adopt comprehensive IVM policies which embrace wider range of control measures, complementing existing strategies and adapting to the evolving challenges of drug resistance.\u003c/p\u003e\u003cp\u003eA limitation of the study is that the findings were largely based on Malaria Indicator Surveys and Uganda Demographic and Surveys which are conducted after relatively long periods and use cross-sectional study designs hence cannot make inferences on behaviour change over time. In addition, due to the nature of the scoping review, rigorous critical appraisal of the included articles was not conducted. Nevertheless, this is one of the few scoping reviews to document Uganda\u0026rsquo;s progress on key malaria indicators over the past two decades as the country aims to progress towards malaria pre-elimination.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUganda has registered considerable progress on malaria indicators in the past two and half decades. Knowledge and practices on major malaria prevention and control indicators have significantly improved. Interventions such as LLINs, IRS and case management have been embraced and scaled up, while others such as LSM and environmental management have been largely neglected. Uganda has adopted different malaria control policies in accordance with WHO guidelines despite challenges in some interventions such as IPTp and iCCM. Progress towards malaria pre-elimination requires a multi-sectoral approach and refocusing political commitment to currently underutilized IVM strategies. Continued engagement of communities is crucial to further bridge the existing gap between knowledge and practices on malaria control.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACTs: artimesinin combination therapies; CHW: Community Health Worker; CQ: Chloroquine; iCCM: Integrated Community Case Management; IRS: Indoor Residual Spraying; IPTp: Intermittent Preventive Treatment during pregnancy; IVM: Integrated Vector Management: LLINs; Long Lasting Insecticidal Nets; LSM: larval source management; MOH: Ministry of Health; NMCP: National Malaria Control Programme; SP: sulfadoxine pyrimethamine; VHT: village health team; WHO: World Health Organization\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria through The AIDS Support Organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDM, AY and MT conceived the study. SN conducted the initial review with the support of DM and AY. SN, DM, SN, AY and MT were involved in writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e The AIDS Support Organization, Kampala, Uganda.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Ministry of Health, Kampala, Uganda\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge all partners who have supported our malaria research in Uganda in recent years including the National Malaria Control Division at Ministry of Health and various District Health Teams.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMinistry of Health. (2020). The Uganda Malaria Reduction and Elimination Strategic Plan 2021-2025.\u003c/li\u003e\n\u003cli\u003eMinistry of Health. (2018). Uganda Malaria Annual Report July 2017-June 2018. Kampala, Uganda.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2023). World Malaria Report/ Uganda. Available from \u0026lt;https://www.who.int/malaria/publications/country-profiles/profile_uga_en.pdf?ua=1\u0026gt; [Accessed on 1/9/2024].\u003c/li\u003e\n\u003cli\u003eMatovu F, Nanyiti A, Rutebemberwa E. Household health care-seeking costs: experiences from a randomized, controlled trial of community-based malaria and pneumonia treatment among under-fives in eastern Uganda. Malar J. 2014 Jun 5;13:222. doi: 10.1186/1475-2875-13-222.\u003c/li\u003e\n\u003cli\u003eMinistry of Health. (2014). The Uganda malaria reduction strategic plan 2014-2020. Kampala, Uganda. Available from \u0026lt;https://health.go.ug/sites/default/files/The%20Uganda%20Malaria%20Reduction%20Strategic%20Plan%202014-2020.pdf\u0026gt; [Accessed on 20th/09/2019].\u003c/li\u003e\n\u003cli\u003eWorld Bank. (2016) Uganda Poverty Assessment 2016: Fact Sheet. Available from \u0026lt;https://www.worldbank.org/en/country/uganda/brief/uganda-poverty-assessment-2016-fact-sheet\u0026gt; [Accessed on 1/9/2019].\u003c/li\u003e\n\u003cli\u003eMinistry of Health. Uganda Malaria Annual Report July 2018-June 2019. Kampala, Uganda. 2019. Available from https://www.moh.gov. [Accessed 1/9/2019].\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. World Malaria Report 2020. 20 years of Global Progress and challenges. Geneva: WHO; 2020, p.2020.\u003c/li\u003e\n\u003cli\u003eLynch C, Hewitt S. Malaria in the Asia-Pacific: burden, success and challenges. Sydney, Australia: Malaria. 2012.\u003c/li\u003e\n\u003cli\u003eMalaria Consortium. Historic campaign delivers mosquito nets to every household across Uganda. Kampala: Malaria Consortium; 2014. http://www.malariaconsortium.org/news-centre/historic-campaign-delivers-mosquito-nets-to-every-household-across-uganda.htm. Accessed 19 March 2020.\u003c/li\u003e\n\u003cli\u003eMinistry of Health. Launch of the LLIN Mosquito Net Campaign 2020. Kampala: Ministry of Health; 2020. https://www.health.go.ug/cause/launch-of-the-llin-mosquito-net-2020-campaign. Accessed 10 March 2020.\u003c/li\u003e\n\u003cli\u003eUganda National Malaria Control Division (NMCD), Uganda Bureau of Statistics (UBOS), and Inner City Fund (ICF). 2020. Uganda Malaria Indicator Survey 2018-19. Kampala, Uganda, and Rockville, Maryland, USA: NMCD, UBOS, and ICF. Available from: https://dhsprogram.com/publications/publication-MIS34-MIS-Final-Reports.cfm. Accessed 1/11/2021.\u003c/li\u003e\n\u003cli\u003eU.S. President\u0026rsquo;s Malaria Initiative Uganda Malaria Operational Plan FY 2023. Retrieved from www.pmi.gov\u003c/li\u003e\n\u003cli\u003eMinistry of Health. Health Sector Strategic Plan III 2010/11-2014/15. 2010. Available from https://health.go.ug/docs/HSSP_III_2010.pdf. Accessed on 15/11/2021.\u003c/li\u003e\n\u003cli\u003eMusoke D, Namata C, Ndejjo R, Ssempebwa JC, Musoke MB. Integrated malaria prevention in rural communities in Uganda: a qualitative feasibility study for a randomised controlled trial. Pilot Feasibility Stud. 2021;7(1):155. doi: 10.1186/s40814-021-00894-0.\u003c/li\u003e\n\u003cli\u003eAdams J, Hillier-Brown FC, Moore HJ, Lake AA, Araujo-Soares V, White M, et al. Searching and synthesising \u0026lsquo;grey literature\u0026rsquo; and \u0026lsquo;grey information\u0026rsquo; in public health: critical reflections on three case studies. Syst Rev. 2016;5:164.\u003c/li\u003e\n\u003cli\u003eMcGowan J, Sampson M, Lefebvre C. An evidence based check-list for the peer review of electronic search strategies (PRESS EBC). Evid Based Lib and Info Pract. 2010;5:149-54.\u003c/li\u003e\n\u003cli\u003eJoanna Briggs Institute. Joanna Briggs Institute reviewers\u0026rsquo; manual: 2014 edition. \u003cem\u003eAustralia: The Joanna Briggs Institute\u003c/em\u003e. 2014.\u003c/li\u003e\n\u003cli\u003eATLAS.ti Scientific Software Development GmbH. Available from www.atlas-ti.com\u003c/li\u003e\n\u003cli\u003eKastner M, Tricco AC, Soobiah C, Lillie E, Perrier L, Horsley T, et al. What is the most appropriate knowledge synthesis method to conduct a review? Protocol for a scoping review. BMC Med Res Methodol. 2012;12(1):1-0.\u003c/li\u003e\n\u003cli\u003ePeters, M.D., Godfrey, C.M., Khalil, H., McInerney, P., Parker, D. and Soares, C.B. Guidance for conducting systematic scoping reviews.Int J Evid Based Healthc, 2015, 13(3), pp.141-146.\u003c/li\u003e\n\u003cli\u003eUganda Bureau of Statistics (UBOS) and ICF International. Uganda Malaria Indicator Survey 2014-15. Kampala, Uganda, and Rockville, Maryland, USA: UBOS and ICF International. 2015\u003c/li\u003e\n\u003cli\u003eUganda Bureau of Statistics (UBOS) and ICF Macro. Uganda Malaria Indicator Survey 2009. Calverton, Maryland, USA: UBOS and ICF Macro. 2010\u003c/li\u003e\n\u003cli\u003eRek J, Musiime A, Zedi M, Otto G, Kyagamba P, Asiimwe Rwatooro J, Arinaitwe E, Nankabirwa J, Staedke SG, Drakeley C, Rosenthal PJ. Non-adherence to long-lasting insecticide treated bednet use following successful malaria control in Tororo, Uganda. PloS One; 2020; 15(12):e0243303.\u003c/li\u003e\n\u003cli\u003eKiggundu VL., O\u0026apos;Meara WP., Musoke R., Nalugoda, FK., Kigozi G., Baghendaghe E., Lutalo T., Achienge MK., Reynolds SJ., Makumbi F. and Serwadda D. (2013). High prevalence of malaria parasitemia and anemia among hospitalized children in Rakai, Uganda. PLoS One, \u003cem\u003e8\u003c/em\u003e(12), p.e82455.\u003c/li\u003e\n\u003cli\u003eLindblade KA, O\u0026apos;neill DB, Mathanga DP, Katungu J, Wilson ML. Treatment for clinical malaria is sought promptly during an epidemic in a highland region of Uganda. Trop Med Int Health. 2008; 5(12): 865-875.\u003c/li\u003e\n\u003cli\u003eNdyomugyenyi R, Magnussen P, Clarke S. Malaria treatment-seeking behaviour and drug prescription practices in an area of low transmission in Uganda: implications for prevention and control. Trans R Soc Trop Med Hyg. 2007;101(3):209-15.\u003c/li\u003e\n\u003cli\u003eMbonye AK, Mohamud SM, Bagonza J. Perceptions and practices for preventing malaria in pregnancy in a peri-urban setting in south-western Uganda. Malaria Journal. 2016 Dec;15(1):1-5.\u003c/li\u003e\n\u003cli\u003eMbonye AK, Neema S, Magnussen P. Treatment-seeking practices for malaria in pregnancy among rural women in Mukono district, Uganda. J Biosoc Sci. 2006;38(2):221-37..\u003c/li\u003e\n\u003cli\u003eMusoke D, Karani G, Morris K, Ndejjo R, Atusingwize E, Guwatudde D, Musoke MB. Integrated approach to malaria prevention at household level in rural communities in Wakiso district, Uganda: impact evaluation of a pilot project. Afr Health Sci. 2018 Dec;18(4):1144-1156. \u003c/li\u003e\n\u003cli\u003eWanzira H, Katamba H, Rubahika D. Use of long-lasting insecticide-treated bed nets in a population with universal coverage following a mass distribution campaign in Uganda Malar J. 2016; 15:311. \u003c/li\u003e\n\u003cli\u003eBerkley JA, Maitland K, Mwangi I, Ngetsa C, Mwarumba S, Lowe BS, Newton CR, Marsh K, Scott JA, English M. Use of clinical syndromes to target antibiotic prescribing in seriously ill children in malaria endemic area: observational study. BMJ. 2005 Apr 30;330(7498):995. doi: 10.1136/bmj.38408.471991.8F. Epub 2005 Mar 29. PMID: 15797893; PMCID: PMC557145. \u003c/li\u003e\n\u003cli\u003eBatwala V, Magnussen P, Hansen KS, Nuwaha F. Cost-effectiveness of malaria microscopy and rapid diagnostic tests versus presumptive diagnosis: implications for malaria control in Uganda. Malar J. 2011 Dec 19;10:372. doi: 10.1186/1475-2875-10-372. PMID: 22182735; PMCID: PMC3266346.\u003c/li\u003e\n\u003cli\u003eBawate C, Callender-Carter ST, Nsajju B, Bwayo D. Factors affecting adherence to national malaria treatment guidelines in management of malaria among public healthcare workers in Kamuli District, Uganda. Malar J. 2016;15:112.\u003c/li\u003e\n\u003cli\u003eMinistry of Health. Monitoring and evaluation plan for Uganda malaria reduction strategic plan, Kampala; 2014.\u003c/li\u003e\n\u003cli\u003eKigozi RN, Bwanika J, Goodwin E, Thomas P, Bukoma P, Nabyonga P, Isabirye F, Oboth P, Kyozira C, Niang M, Belay K, Sebikaari G, Tibenderana JK, Gudoi SS. Determinants of malaria testing at health facilities: the case of Uganda. Malar J. 2021 Dec 4;20(1):456. doi: 10.1186/s12936-021-03992-9. PMID: 34863172; PMCID: PMC8645102. \u003c/li\u003e\n\u003cli\u003eUganda Ministry of Health, National Malaria Control Division, Surveillance Monitoring \u0026amp; Evaluation Unit. 2019. National Malaria Annual Report 2017-2018, Kampala, Uganda https://health.go.ug/publications.\u003c/li\u003e\n\u003cli\u003eUganda Ministry of Health, National Malaria Control Division, Surveillance Monitoring \u0026amp; Evaluation Unit. 2022. National Malaria Annual Report 2021-2022, Kampala, Uganda https://health.go.ug/publications\u003c/li\u003e\n\u003cli\u003eStaedke SG, Mpimbaza A, Kamya MR, Nzarubara BK, Dorsey G, Rosenthal PJ. Combination treatments for uncomplicated falciparum malaria in Kampala, Uganda: randomised clinical trial. The Lancet. 2004 Nov 27;364(9449):1950-7.\u003c/li\u003e\n\u003cli\u003eYeka A, Banek K, Bakyaita N, Staedke SG, Kamya MR, Talisuna A, Kironde F, Nsobya SL, Kilian A, Slater M, Reingold A, Rosenthal PJ, Wabwire-Mangen F, Dorsey G. Artemisinin versus nonartemisinin combination therapy for uncomplicated malaria: randomized clinical trials from four sites in Uganda. PLoS Med. 2005 Jul;2(7):e190. doi: 10.1371/journal.pmed.0020190. Epub 2005 Jul 26. PMID: 16033307; PMCID: PMC1181876.\u003c/li\u003e\n\u003cli\u003eMinistry of Health, Uganda, National policy on malaria treatment 2005, 2005, http://www.health.go.ug/mcp/NationalPolicy\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, Position of WHO\u0026prime;s Roll Back Malaria Department on malaria treatment policy, 2003, http://www.who.int/malaria/publications/ato\u003c/li\u003e\n\u003cli\u003eKibira, D., Ssebagereka, A., van den Ham, H.A., Opigo, J., Katamba, H., Seru, M., Reed, T., Leufkens, H.G. and Mantel-Teeuwisse, A.K., 2021. Trends in access to anti‐malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first‐line anti‐malarials and diagnostics between 2007 and 2018. Malaria Journal, 20, pp.1-8.\u003c/li\u003e\n\u003cli\u003eKwiringira A, Nanziri C, Nsubuga EJ, Migamba SM, Ntono V, Atuhaire I, Ahirirwe SR, Asio A, Senyange S, Nakamya P, Masanja V, Elayeete S, Komakech A, Nansikombi HT, Mwine P, Nampeera R, Ndyabakira A, Okello P, Migisha R, Bulage L, Kwesiga B, Kadobera D, Rutazaana D, Harris JR, Ario AR. Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021. Malar J. 2022 Dec 3;21(1):367. doi: 10.1186/s12936-022-04401-5. PMID: 36463150; PMCID: PMC9719168. \u003c/li\u003e\n\u003cli\u003eUganda Bureau of Statistics (UBOS) and ICF International Inc. Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc. 2012.\u003c/li\u003e\n\u003cli\u003eUganda Bureau of Statistics. Uganda National Household Survey 2005/6. Kampala, Uganda. 2006\u003c/li\u003e\n\u003cli\u003eUganda Bureau of Statistcs (UBOS) and ICF International. Uganda Demographic and Health Survey 2016: Key Indicators Report. Kampala, Uganda: UBOS, and Rockville, Maryland, USA: UBOS and ICF International. 2018.\u003c/li\u003e\n\u003cli\u003eter Kuile FO, van Eijk AM, Filler SJ. Effect of sulfadoxine-pyrimethamine resistance on the efficacy of intermittent preventive therapy for malaria control during pregnancy: a systematic review. JAMA. 2007;297(23): 2603-2616.\u003c/li\u003e\n\u003cli\u003eAmeyaw EK. Uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in Uganda: a national survey. Malar J. 2022 Oct 7;21(1):285. doi: 10.1186/s12936-022-04299-z. PMID: 36207727; PMCID: PMC9547429. \u003c/li\u003e\n\u003cli\u003eRaouf S, Mpimbaza A, Kigozi R, Sserwanga A, Rubahika D, Katamba H, et al. Resurgence of Malaria Following Discontinuation of Indoor Residual Spraying of Insecticide in an Area of Uganda With Previously High-Transmission Intensity. Clin Infect Dis. 2017;65(3):453\u0026ndash;60. pmid:28369387; PubMed Central PMCID: PMC5850037. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Compendium of WHO malaria guidance: prevention, diagnosis, treatment, surveillance and elimination. World Health Organization; 2019.\u003c/li\u003e\n\u003cli\u003eUganda Bureau of Statistics.Uganda National Household Survey 2001/2. Kampala, Uganda. 2002.\u003c/li\u003e\n\u003cli\u003eTukei BB, Beke A, Lamadrid-Figueroa H. Assessing the effect of indoor residual spraying (IRS) on malaria morbidity in Northern Uganda: a before and after study. Malar J. 2017;16(1):4.\u003c/li\u003e\n\u003cli\u003eKigozi R, Baxi SM., Gasasira A, Sserwanga A, Kakeeto S, Nasr S, Rubahika D, Dissanayake G, Kamya M. R., Filler S, Dorsey G. Indoor Residual Spraying of Insecticide and Malaria Morbidity in a High Transmission Intensity Area of Uganda. PLoS One. 2012;7: e42857.\u003c/li\u003e\n\u003cli\u003eSimple O, Mindra A, Obai G, Ovuga E, Odongo-Aginya EI. Influence of Climatic Factors on Malaria Epidemic in Gulu District, Northern Uganda: A 10-Year Retrospective Study. Malar Res Treat. 2018 Aug 13;2018:5482136. \u003c/li\u003e\n\u003cli\u003eMusoke D, Nyashanu M, Bugembe H, Lubega GB, O\u0026apos;Donovan J, Halage AA, Gibson L. Contested notions of challenges affecting Community Health Workers in low- and middle-income countries informed by the Silences Framework. Hum Resour Health. 2022 Jan 6;20(1):4. doi: 10.1186/s12960-021-00701-0. PMID: 34991590; PMCID: PMC8734299. \u003c/li\u003e\n\u003cli\u003eAwor P, Kalyango JN, St\u0026aring;lsby Lundborg C, Ssengooba F, Eriksen J, Rutebemberwa E. Policy Challenges Facing the Scale Up of Integrated Community Case Management (iCCM) in Uganda. Int J Health Policy Manag. 2022 Aug 1;11(8):1432-1441. doi: 10.34172/ijhpm.2021.39. Epub 2021 May 24. PMID: 34124867; PMCID: PMC9808347. \u003c/li\u003e\n\u003cli\u003eMusoke D, Ndejjo R, Atusingwize E, Ssemugabo C, Ottosson A, Gibson L, Waiswa P. Panacea or pitfall? The introduction of community health extension workers in Uganda. BMJ Glob Health. 2020 Aug;5(8):e002445. doi: 10.1136/bmjgh-2020-002445. PMID: 32816827; PMCID: PMC7430324. \u003c/li\u003e\n\u003cli\u003eO\u0026apos;Donovan J, Stiles CE, Sekimpi D, Ddumba I, Winters N, O\u0026apos;Neil E Jr. Potential challenges of implementing the Community Health Extension Worker programme in Uganda. BMJ Glob Health. 2018 Aug 10;3(4):e000960. doi: 10.1136/bmjgh-2018-000960. PMID: 30116596; PMCID: PMC6089279.\u003c/li\u003e\n\u003cli\u003eKaufman MR, Rweyemamu D, Koenker H, Macha J (2012). \u0026quot;My children and I will no longer suffer from malaria\u0026quot;: a qualitative study of the acceptance and rejection of indoor residual spraying to prevent malaria in Tanzania. Malar J. 2012; 11: 220. \u003c/li\u003e\n\u003cli\u003eWHO. Policy recommendation: seasonal malaria chemoprevention (SMC) for Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa. Geneva: World Health Organization; 2012.\u003c/li\u003e\n\u003cli\u003eNakkazi E. Karamojong people embrace malaria chemoprevention. Lancet Infect Dis. 2021 Nov;21(11):1499. doi: 10.1016/S1473-3099(21)00636-8. PMID: 34717809. \u003c/li\u003e\n\u003cli\u003eKigozi SP, Kigozi RN, Sebuguzi CM, Cano J, Rutazaana D, Opigo J, Bousema T, Yeka A, Gasasira A, Sartorius B, Pullan RL. Spatial-temporal patterns of malaria incidence in Uganda using HMIS data from 2015 to 2019. BMC Public Health. 2020 Dec 14;20(1):1913. doi: 10.1186/s12889-020-10007-w. PMID: 33317487; PMCID: PMC7737387. \u003c/li\u003e\n\u003cli\u003eWennstr\u0026ouml;m P. Cattle, conflict, and climate variability: explaining pastoralist conflict intensity in the Karamoja region of Uganda. Regional Environ Change. 2024;24:54. \u003c/li\u003e\n\u003cli\u003eKwiringira A, Kwesiga B, Migisha R, Bulage L, Kadobera D, Rutazaana D, Harris JR, Ario AR, Ssempiira J. Effect of seasonal malaria chemoprevention on incidence of malaria among children under five years in Kotido and Moroto Districts, Uganda, 2021: time series analysis. Malar J. 2024 Dec 18;23(1):389. doi: 10.1186/s12936-024-05220-6. PMID: 39695723; PMCID: PMC11657844. \u003c/li\u003e\n\u003cli\u003eNuwa A, Baker K, Kajubi R, Nnaji CA, Theiss-Nyland K, Odongo M, Kyagulanyi T, Nabakooza J, Salandini D, Asua V, Nakirunda M. Effectiveness of sulfadoxine\u0026ndash;pyrimethamine plus amodiaquine and dihydroartemisinin\u0026ndash;piperaquine for seasonal malaria chemoprevention in Uganda: a three-arm, open-label, non-inferiority and superiority, cluster-randomised, controlled trial. The Lancet Infectious Diseases. 2025 Jan 15.\u003c/li\u003e\n\u003cli\u003eKamya MR, Bakyaita NN, Talisuna AO, Were WM, Staedke SG. Increasing antimalarial drug resistance in Uganda and revision of the national drug policy. Trop Med Int Health. 2002;7(12):1031-41.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2010) Global report on antimalarial drug efficacy and drug resistance: 2000\u0026ndash;2010. Available from: http://www.searo.who.int/LinkFiles/Malaria_antimalarial_drug_efficacy10.pdf. Accessed on 29/8/2019.\u003c/li\u003e\n\u003cli\u003eTalisuna AO, Nalunkuma-Kazibwe A, Bakyaita N, Langi P, Mutabingwa TK, Watkins WW, et al. Efficacy of sulphadoxine-pyrimethamine alone or combined with amodiaquine or chloroquine for the treatment of uncomplicated falciparum malaria in Ugandan children. Trop Med Int Health. 2004;9(2):222-9.\u003c/li\u003e\n\u003cli\u003eBakyaita N, Dorsey G, Yeka A, Banek K, Staedke SG, Kamya MR. et al. Sulfadoxine-pyrimethamine plus chloroquine or amodiaquine for uncomplicated falciparum malaria: a randomized, multisite trial to guide national policy in Uganda. Am J Trop Med Hyg. 2005;72(5):573-580.\u003c/li\u003e\n\u003cli\u003eJima D, Getachew A, Bilak H, Steketee RW, Emerson PM, Graves PM, et al. Ethiopia Malaria Indicator Survey Working Group. Malaria indicator survey 2007, Ethiopia: coverage and use of major malaria prevention and control interventions. Malar J. 2010;9:58. \u003c/li\u003e\n\u003cli\u003eChizema-Kawesha E, Miller JM, Steketee RW, Mukonka VM, Mukuka C, Mohamed AD, et al. Scaling up malaria control in Zambia: progress and impact 2005-2008. Am J Trop Med Hyg. 2010;83(3):480-8.\u003c/li\u003e\n\u003cli\u003eSande S, Zimba M, Mberikunashe J, Tangwena A, Chimusoro A. Progress towards malaria elimination in Zimbabwe with special reference to the period 2003-2015. Malar J. 2017;16(1):295.\u003c/li\u003e\n\u003cli\u003eCibulskis RE, Alonso P, Aponte J, Aregawi M, Barrette A, Bergeron L, et al. Malaria: Global progress 2000 - 2015 and future challenges. Infect Dis Poverty. 2016;5(1):61. \u003c/li\u003e\n\u003cli\u003eKilleen GF. Control of malaria vectors and management of insecticide resistance through universal coverage with next-generation insecticide-treated nets. The Lancet. 2020 Apr 25;395(10233):1394-400.\u003c/li\u003e\n\u003cli\u003eLouis VR, Schoeps A, Tiendreb\u0026eacute;ogo J, Beiersmann C, Y\u0026eacute; M, Damiba MR, Lu GY, Mbayiha AH, De Allegri M, Jahn A, Si\u0026eacute; A, Becher H, M\u0026uuml;ller O. An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso. Bull World Health Organ. 2015;93(11):750-8. \u003c/li\u003e\n\u003cli\u003eCoulibaly D, Travassos MA, Kone AK, Tolo Y, Laurens MB, Traore K, et al. Stable malaria incidence despite scaling up control strategies in a malaria vaccine-testing site in Mali. Malar J. 2014;13:374.\u003c/li\u003e\n\u003cli\u003eMukonka VM, Chanda E, Haque U, Kamuliwo M, Mushinge G, Chileshe J, et al. High burden of malaria following scale-up of control interventions in Nchelenge District, Luapula Province, Zambia. Malar J. 2014;13:153.\u003c/li\u003e\n\u003cli\u003eTangena JA, Hendriks CMJ, Devine M, Tammaro M, Trett AE, Williams I, et al. Indoor residual spraying for malaria control in sub-Saharan Africa 1997 to 2017: an adjusted retrospective analysis. Malar J. 2020;19(1):150. doi: 10.1186/s12936-020-03216-6. \u003c/li\u003e\n\u003cli\u003eBath D, Cook J, Govere J, Mathebula P, Morris N, Hlongwana K, Raman J, Seocharan I, Zitha A, Zitha M, Mabuza A. Effectiveness and cost-effectiveness of reactive, targeted indoor residual spraying for malaria control in low-transmission settings: a cluster-randomised, non-inferiority trial in South Africa. The Lancet. 2021 Feb 27;397(10276):816-27.\u003c/li\u003e\n\u003cli\u003eOppong FB, Gyaase S, Zandoh C, Nettey OEA, Amenga-Etego S, Anane EA, et al. Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015. BMJ Open. 2019;9(6):e027946. doi: 10.1136/bmjopen-2018-027946. \u003c/li\u003e\n\u003cli\u003eACCESS-SMC Partnership. Effectiveness of seasonal malaria chemoprevention at scale in west and central Africa: an observational study. Lancet. 2020 Dec 5;396(10265):1829-1840. doi: 10.1016/S0140-6736(20)32227-3. PMID: 33278936; PMCID: PMC7718580\u003c/li\u003e\n\u003cli\u003eKyabayinze DJ, Asiimwe C, Nakanjako D, Nabakooza J, Counihan H, Tibenderana JK. Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda. Malar J. 2010 Jul 12;9:200. doi: 10.1186/1475-2875-9-200. PMID: 20624312; PMCID: PMC2914063. \u003c/li\u003e\n\u003cli\u003eArnaldo P, Rovira-Vallbona E, Langa JS, Salvador C, Guetens P, Chiheb D, et al. Uptake of intermittent preventive treatment and pregnancy outcomes: health facilities and community surveys in Ch\u0026oacute;kw\u0026egrave; district, southern Mozambique. Malar J. 2018;17(1):109. doi: 10.1186/s12936-018-2255-z.\u003c/li\u003e\n\u003cli\u003eChanda E, Mzilahowa T, Chipwanya J, Ali D, Troell P, Dodoli W, et al. Scale-up of integrated malaria vector control: lessons from Malawi. Bull World Health Organ. 2016;94(6):475-80. doi: 10.2471/BLT.15.154245.\u003c/li\u003e\n\u003cli\u003eMutero CM, Schlodder D, Kabatereine N, Kramer R. Integrated vector management for malaria control in Uganda: knowledge, perceptions and policy development. Malar J. 2012;11:21. doi: 10.1186/1475-2875-11-21. \u003c/li\u003e\n\u003cli\u003eTownson H, Nathan MB, Zaim M, Guillet P, Manga L, Bos R, Kindhauser M. Exploiting the potential of vector control for disease prevention. Bull World Health Organ. 2005 Dec;83(12):942-7.\u003c/li\u003e\n\u003cli\u003eKisia J, Nelima F, Otieno DO, Kiilu K, Emmanuel W, Sohani S, Siekmans K, Nyandigisi A, Akhwale W. Factors associated with utilization of community health workers in improving access to malaria treatment among children in Kenya. Malar J. 2012;11:248. doi: 10.1186/1475-2875-11-248.\u003c/li\u003e\n\u003cli\u003eMsellem MI, M\u0026aring;rtensson A, Rotllant G, Bhattarai A, Str\u0026ouml;mberg J, Kahigwa E, Garcia M, Petzold M, Olumese P, Ali A, Bj\u0026ouml;rkman A. Influence of rapid malaria diagnostic tests on treatment and health outcome in fever patients, Zanzibar: a crossover validation study. PLoS Med. 2009 Apr 28;6(4):e1000070. doi: 10.1371/journal.pmed.1000070. Epub 2009 Apr 28. PMID: 19399156; PMCID: PMC2667629. \u003c/li\u003e\n\u003cli\u003eAjayi IO, Nsungwa-Sabiiti J, Siribi\u0026eacute; M, Falade CO, Serm\u0026eacute; L, Balyeku A, Afonne C, Sanou AK, Kabarungi V, Oshiname FO, Gansane Z, Kyaligonza J, Jegede AS, Tiono AB, Sirima SB, Diarra A, Yusuf OB, Fouque F, Castellani J, Petzold M, Singlovic J, Gomes M. Feasibility of Malaria Diagnosis and Management in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study. Clin Infect Dis. 2016 Dec 15;63(suppl 5):S245-S255. doi: 10.1093/cid/ciw622. PMID: 27941101; PMCID: PMC5146694. \u003c/li\u003e\n\u003cli\u003ePallas SW, Minhas D, P\u0026eacute;rez-Escamilla R, Taylor L, Curry L, Bradley EH. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability? Am J Public Health. 2013;103(7):e74-82.\u003c/li\u003e\n\u003cli\u003eEmukah EC, Enyinnaya U, Olaniran NS, Akpan EA, Hopkins DR, Miri ES, et al. Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria. Ann Trop Med Parasitol. 2008;102(1):45-51.\u003c/li\u003e\n\u003cli\u003eChuke NU, Okafor SO, Mbagwu FO, Ike OO, Ogbonna AN, Okoye OE. Rural Health Workers and Primary Health Care Promotion in Southeast Nigeria: Challenges and Their Implication to Community and Sustainable Development. International Journal of Sustainable Development \u0026amp; Planning. 2023 Jan 1;18(1).\u003c/li\u003e\n\u003cli\u003eSimon S, Chu K, Frieden M, Candrinho B, Ford N, Schneider H, et al. An integrated approach of community health worker support for HIV/AIDS and TB care in Ang\u0026oacute;nia district, Mozambique. BMC Int Health Hum Rights. 2009;9:13.\u003c/li\u003e\n\u003cli\u003eMusoke D, Miiro G, Ndejjo, R., Karani G, Morris K, Kasasa S, et al. Malaria prevention practices and associated environmental risk factors in a rural community in Wakiso district, Uganda. PLoS One 2018;13(10): e0205210.\u003c/li\u003e\n\u003cli\u003eKalyango JN, Rutebemberwa E, Alfven T, Ssali S, Peterson S, Karamagi C. Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda. Malar J. 2012;11:282.\u003c/li\u003e\n\u003cli\u003eChipukuma HM, Zulu JM, Jacobs C, Chongwe G, Chola M, Halwiindi H,et al. Towards a framework for analyzing determinants of performance of community health workers in malaria prevention and control: a systematic review. Hum Resour Health. 2018;16(1):1-6.\u003c/li\u003e\n\u003cli\u003eWinn LK, Lesser A, Menya D, Baumgartner JN, Kirui JK, Saran I, et al. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health. 2018;8(1).\u003c/li\u003e\n\u003cli\u003eNalinya S, Musoke D, Deane K. Malaria prevention interventions beyond long-lasting insecticidal nets and indoor residual spraying in low- and middle-income countries: a scoping review. Malar J. 2022 Feb 2;21(1):31. doi: 10.1186/s12936-022-04052-6.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Handbook for integrated vector management. World Health Organization; 2012.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malaria, prevention, control, elimination, integrated vector management, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-7802394/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7802394/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eUganda ranks among the top five countries with the highest global burden of malaria cases and deaths. Although Uganda has made progress in the scale up of key malaria control interventions, there remains a significant gap in achieving universal coverage for impact. By the end of 2025, the National Malaria Control Division (NMCD) aimed to reduce malaria morbidity by 50% and malaria related mortality by 75% of the 2019 levels.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eThe aim of this scoping review was to examine available literature on malaria prevention and control in Uganda to gain an insight on the progress, identify gaps and opportunities on the implementation of control strategies. This aimed to inform practice, policy and programs and provide direction for future research priorities to propel the country to malaria elimination.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e\u003cp\u003eThe study involved reviewing published on malaria indicators from the year 2000 to 2024. Literature was obtained from PubMed, the Cochrane Library, Uganda Demographic Health Surveys, Uganda Malaria Indicator Surveys, Malaria Program Reviews and other sources. The search strategy included all study designs and was limited to those in English. Three independent reviewers performed the selection and characterization of articles, and the data was qualitatively synthesized.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 3,619 articles were identified and 38 were included in the analysis. The results were grouped into 3 major themes of: knowledge; practices; and policies for malaria prevention and control. The level of knowledge among adults on the different aspects of malaria was generally high and has increased over the past two and half decades. Coverage of interventions have remarkably improved over the years. Ownership of LLINs significantly increased from 13% in 2001 to 95% in 2021. The use of long-lasting insecticidal nets (LLINs) was at 69% in 2021. Intermittent preventive treatment for malaria during pregnancy (IPTp) have increased but still below the target, from 16% in 2006 to 72% in 2019. Seasonal Malaria Chemoprevention has been piloted with promising results. Progress on environmental management and integrated community case management of childhood illnesses for malaria control has been slow. Various malaria policies have been adopted such as universal coverage for LLINs, and artemisinin combination therapies for uncomplicated malaria.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eUganda has made significant progress on different malaria prevention and control indicators. However, coverage of interventions is suboptimal to achieve malaria elimination. Innovations are needed in malaria control coupled with a multi-sectoral approach and political commitment to achieve malaria elimination.\u003c/p\u003e","manuscriptTitle":"Achievements in malaria prevention and control in Uganda: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 14:25:03","doi":"10.21203/rs.3.rs-7802394/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-10-12T10:13:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-08T06:16:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-08T06:16:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2025-10-07T19:53:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73949023-98d2-484c-b92c-678ef1d18ca5","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T14:25:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-27 14:25:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7802394","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7802394","identity":"rs-7802394","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}