Assessing the acceptability and feasibility of proactive community case management: A qualitative study in Chadiza District, Zambia

Zambia has implemented passive malaria community case management (CCM), during which symptomatic people seek care at a community health workers (CHW) abode, since 2011. In 2021, the National Malaria Elimination Program implemented a two-arm cluster-randomized controlled trial to measure the impact of proactive CCM (ProCCM) compared to routine passive CCM on malaria incidence and prevalence in Chadiza District, Eastern Province. ProCCM is a strategy of regular visits by CHWs to all households in a community to identify people with malaria symptoms, provide rapid diagnostic testing, and treat those with malaria with artemisinin combination therapy. We conducted a qualitative midline assessment of this trial to describe the feasibility and acceptability of ProCCM. Key informant interviews (KIIs) were conducted with CHWs provincial and district staff, health facility staff, and community leaders, while focus group discussions were conducted with community members from six ProCCM and six passive CCM clusters. All respondent groups preferred ProCCM to passive CCM, reporting that it reduces distance travelled to seek care and provides care to people with challenges accessing it. Most CHWs and health facility staff perceived the ProCCM arm to have less malaria compared to the passive arm. Six provincial, district, and health facility staff and five CHWs felt that ProCCM was onerous for CHWs, necessitating compensation. Four health facility staff reported supervising ProCCM CHWs more frequently than before the trial, which two saw as an additional, albeit manageable, time commitment. District and health facility staff noted an increase in commodities consumption due to ProCCM. Other challenges included long distances covered by CHWs during visits and the impact of the farming cycle on both households and CHWs availability for visits. The findings suggest that ProCCM is both feasible to implement and acceptable to communities but requires additional time and travel for CHWs.