Severe malaria among children under five years in rural Uganda in 2024: prevalence, socio-demographic factors and caregiver’s knowledge

Background Malaria remains a major public health challenge in sub-Saharan Africa, with children under five years bearing the highest burden of severe disease and mortality. Uganda is among the countries with the highest malaria prevalence globally, yet evidence on the prevalence and determinants of severe malaria among children under-five remains limited. This study assessed the prevalence of severe malaria among children under five and examined associated socio-demographic factors, caregiver knowledge of malaria prevention and severe symptoms, and healthcare-seeking behaviors in rural high-burden districts of Uganda Methods A community-based cross-sectional study was conducted between December 2022 and March 2023 in 15 districts supported by the Presidential Malaria Initiative through the Uganda Health System Strengthening Activity. Caregivers were recruited through household follow-up of children who had tested positive for malaria at selected government health facilities after line listing. Data was collected using a structured interviewer-administered questionnaire capturing socio-demographic characteristics and caregiver’s knowledge of malaria signs, symptoms, and prevention. Severe malaria was defined based on clinical features consistent with WHO criteria. Data was analyzed using STATA version 17, with descriptive statistics, exploratory factor analysis, and multivariate logistic regression to identify factors associated with severe malaria. Results A total of 1,886 participants were enrolled, yielding a response rate of 96.9%. Severe malaria was identified in 80.3% of children under five years old. Region of residence, caregiver’s educational level, type of housing, and level of health facility attended were significantly associated with severe malaria among under five years old. Children whose caregivers had secondary education and those living in permanent or mud-walled houses had lower odds of severe malaria compared to those in grass-thatched houses. Conclusion The prevalence of severe malaria among children under five years old in rural Uganda is alarmingly high, suggesting delayed care-seeking and gaps in prevention and early management. Strengthening caregiver’s education, community sensitization, and improving health facility readiness to test and treat malaria particularly in rural areas are critical to reducing severe malaria and related child mortality.