‘Poverty is the biggest barrier’: stakeholder perspectives on social determinants of malaria in Wakiso District, Uganda

BACKGROUND: Despite significant resources invested in malaria control interventions for several years, the disease remains a persistent health challenge impacting millions of people especially children and pregnant women in the lower income regions of the world. Progress towards eliminating malaria has stagnated, in part due to the limited consideration of the social determinants of the disease such as poverty. We conducted a qualitative study exploring stakeholder perspectives on social determinants of malaria including lived experiences with the disease in Wakiso, one of the districts with high malaria cases in Uganda. METHODS: This was a cross-sectional study using fourteen key informant interviews at community, health facility, district and national levels, 10 focus group discussions among community members and community health workers, and 11 in-depth interviews with household heads. Data collection was conducted in English and Luganda (local language), transcribed, coded using Atlas.ti. (version 6) and Nvivo (version 14) and analysed using a thematic approach. This paper focuses on the perspectives on poverty as a social determinant of malaria. RESULTS: The participants linked poverty to malaria through five themes: poor housing conditions; limited access to malaria control services; limited water and sanitation-related exposures; occupational and psychological exposures; and heavy economic burden (consequences) of malaria. The themes are presented under various sub-themes which separately highlight in detail the different pathways of the malaria-poverty relationship. These include: substandard housing structures enabling mosquito exposure; building close to mosquito breeding grounds; homelessness and street life; inadequate malaria prevention and treatment services; limited access to water supply; poor sanitation and waste management practices; occupational exposures; social and psychological constraints; high treatment costs; undernutrition causing low immunity; and loss of income. These perspectives emphasize a cyclic poverty-malaria relationship through the high treatment costs and loss of income due to illness or livelihood disruption. CONCLUSION: Malaria is rooted in economic inequalities suggesting that improvement in malaria control interventions through policies and frameworks that address poverty as a consequence, and driver of the disease should be prioritised. The study underscores the need for integrated malaria control strategies that address vulnerabilities related to poverty in all its dimensions-economic, environmental and psychosocial.