Public health implications of geospatial targeting to prevent malaria infection in under-five children across sub-Saharan Africa.

OBJECTIVES: To assess sub-national variation in malaria positivity among children under five in sub-Saharan Africa and examine whether maternal, household, structural, and healthcare-access factors were associated with higher malaria burden. STUDY DESIGN: Cross-sectional. METHODS: We used pooled Demographic and Health Survey data (2017-2023) from 10 sub-Saharan African countries to assess malaria positivity among children under five. Geospatial smoothing models were used to describe sub-national variation and identify areas of higher malaria positivity. Country-specific factors associated with malaria positivity and corresponding population-level (PAR%) estimates were assessed in multifactorial setting. RESULTS: Malaria positivity varied substantially, ranging from 4% to 38% at the national level and up to 71% in high-burden sub-regions. Rural residence (adjusted Odds Ratio (aOR):2.3-8.3, PAR%>50% in most countries). Structural factors including lack of piped-water, electricity, household-amenities, and maternal education were consistently linked to higher malaria risk in all countries, with PAR% estimates ranging from 60%-to-90% in some countries. Child anemia (aOR >2.0, PAR% up to 51%), recent fever, and inadequate antenatal care were also strong predictors of infection. CONCLUSION: Malaria positivity among children under five was associated with both clinical indicators and structural inequities. Targeted, equity-focused strategies addressing infrastructure, maternal care, and prevention are essential for reducing burden.