Malaria remains one of the foremost public health challenges in sub-Saharan Africa, accounting for a disproportionate burden of morbidity and mortality particularly in rural and resource-limited settings. According to the World Health Organization [1], Zimbabwe is among the 15 countries in sub-Saharan Africa carrying the heaviest malaria burden. Although malaria cases have declined over the past decade, transmission continues to be highly seasonal and concentrated in lowland and border districts, with children under five years and pregnant women bearing the greatest risk [2]. 

Community Engagement (CE) is widely recognised as a critical enabler of sustainable malaria control. Without the active participation of local communities, interventions such as Insecticide-Treated Nets (ITNs), Indoor Residual Spraying (IRS) and Artemisinin-based Combination Therapy (ACT) have demonstrated limited sustained impact [1]. Community Health Workers (CHWs) occupy a strategic position as the interface between formal health systems and households, conducting culturally acceptable health promotion, early case detection and referrals [3,4].             

Centenary District, situated in Mashonaland Central Province, presents a compelling case for studying community engagement in malaria control. The district recorded over 26,000 malaria cases in 2020, with 101 deaths and despite a notable decline to 6,749 cases and 27 deaths by 2024, mortality rates remained persistently elevated at 4.0 per 100,000 population [2]. ITN coverage in the district fell below the national target of 80% and 40% of diagnosed malaria cases were not treated on time, contributing to preventable deaths [5].

Despite the recognised importance of community-driven approaches, limited empirical evidence exists on the specific strategies employed in Centenary District, their perceived effectiveness and the barriers to implementation. This study addresses that evidence gap by exploring the types of community engagement strategies employed, their impact on malaria preventive and treatment-seeking behaviors and the challenges hindering effective implementation. The Socio-Ecological Model (SEM), which accounts for the dynamic interplay of individual, relational, community and societal factors influencing health behaviors [6,7], provides the conceptual anchor for the study.

Literature Review

Global and Regional Evidence on Community Engagement in Malaria Control:

Globally, community engagement has been integrated into national malaria control programmes as a foundational strategy to bridge the gap between formal health services and hard-to-reach populations [1]. Community Health Workers have been deployed across Asia and sub-Saharan Africa to support ITN distribution, health education, malaria case detection and treatment referrals, demonstrating significant improvements in health-seeking behaviour and preventive practices [8,9]. A controlled trial in Ethiopia found that CHW-facilitated interventions reduced time to malaria treatment by supporting round-the-clock case detection at community level [9]. 

In Tanzania and Kenya, community-led distribution of ITNs, combined with peer education and local advocacy, has significantly improved household net use and treatment-seeking [10,11]. In Southern Africa, Mozambique and Zambia have integrated community health volunteers into malaria surveillance systems, achieving reductions in mortality and improved early treatment rates [12,13]. The African Union Malaria Strategy (2020–2030) explicitly recognizes community engagement as indispensable for achieving malaria elimination goals, particularly in rural and peri-urban settings.

Community Engagement in Zimbabwean Malaria Control

Zimbabwe's national malaria control programme, coordinated by the Ministry of Health and Child Care (MOHCC), has embedded community engagement through CHW networks, environmental management campaigns and health education initiatives [14]. In Mashonaland Central Province and districts such as Centenary, community-based ITN distribution coordinated with local leaders and Village Health Workers (VHWs) has produced measurable improvements in net utilisation [15]. Community-based malaria surveillance, in which residents report suspected cases to health authorities, has facilitated timely interventions and contributed to reduced transmission in rural areas [16]. 

Despite these advances, challenges persist. Matinhure et al. [17], identified logistical barriers, cultural beliefs, low literacy and limited infrastructure as significant obstacles to effective community engagement in Zimbabwe's rural districts. Cultural perceptions attributing malaria to spiritual causes reduce uptake of biomedical interventions, while resource constraints limit the operational capacity of CHWs, many of whom remain unpaid volunteers [4,18]. These challenges underscore the importance of localised, contextually grounded evidence to inform programme improvement.

Conceptual Framework

This study is grounded in the Socio-Ecological Model (SEM), which proposes that health behaviours are determined not solely by individual knowledge or attitudes, but by the interaction of individual, interpersonal, community, organisational and policy-level factors [6]. Applied to malaria control in Centenary District, the framework recognises that ITN use, treatment-seeking behaviour and environmental management practices are shaped simultaneously by personal awareness, peer and household dynamics, the mobilisation capacity of CHWs and local leaders, organisational support from health authorities and NGOs and enabling national policies and donor resources. The SEM provides a multi-level lens through which the effectiveness, barriers and opportunities for community engagement in malaria control can be systematically analysed.

Research Design

The study employed a descriptive mixed-methods research design, integrating quantitative survey data with qualitative key informant insights [19]. This approach was selected to capture both measurable patterns in community engagement practices and the contextual, experiential dimensions of malaria control as understood by frontline health workers and district health managers. The mixed-methods design enabled triangulation of findings, enhancing the validity and comprehensiveness of conclusions [20].

Study Setting

The study was conducted in Centenary District, Mashonaland Central Province, Zimbabwe. The district is a malaria-endemic area characterised by rural and peri-urban communities, where Anopheles mosquitoes breed in standing water during the rainy season from November to April [5]. Access to health services is constrained by distance, poor road infrastructure and limited health facility capacity, making community level engagement particularly critical for malaria control.

Study Population and Sampling

The target population comprised healthcare providers working in community malaria control programmes in Centenary District, including CHWs, nurses and medical officers, as well as district health management personnel. A structured questionnaire was administered to 50 healthcare providers selected through stratified random sampling, ensuring balanced representation across professional cadres and demographic characteristics. Three key informants were purposively selected: the District Nursing Officer, the District Environmental Health Officer and the Executive Officer for Health of Centenary Rural District Council. These informants were selected on the basis of their senior roles in overseeing malaria control programmes in the district.

Data Collection

Primary quantitative data were collected through a structured self-administered questionnaire covering respondent demographics, community engagement strategies employed, perceived effectiveness, community understanding, observed changes in malaria prevention practices, barriers to implementation and the role of CHWs. Qualitative data were gathered through semi-structured key informant interviews, allowing respondents to share in-depth perspectives on engagement strategies, challenges and recommendations. Interviews were conducted in a private setting, audio-recorded with consent and subsequently transcribed verbatim. Ethical clearance was obtained from the relevant institutional review committee and written informed consent was secured from all participants prior to data collection.

Data Analysis

Quantitative data were analysed using descriptive statistics, with findings presented as frequencies and percentages to illuminate patterns across the respondent sample. Qualitative data were analysed thematically following the six-phase framework of Braun and Clarke [21], involving data familiarisation, coding, theme identification, review, definition and write-up. Themes were derived from the four research objectives and illustrative participant quotes are presented verbatim to authenticate key findings. Validity was ensured through source triangulation across the questionnaire and key informant data; reliability was strengthened by cross-checking emergent themes across participant categories.

Respondent Characteristics

Table 1 presents the professional roles of the 50 questionnaire respondents. CHWs constituted the largest proportion (50%), reflecting their dominant presence in community-level health service delivery in rural Zimbabwe. Nurses and doctors together comprised 50% of the sample, providing a cross-cadre perspective on malaria control.

Table 1: Professional Role of Respondents

Regarding years of experience, the majority of respondents (60%) had between 11 and 15 years of experience in the health sector, indicating a seasoned workforce with deep familiarity with community malaria dynamics. In terms of educational attainment, 50% held certificates, 30% diplomas and 20% degrees, consistent with the staffing profile of rural health programmes in Zimbabwe.

Community Engagement Strategies Employed in Malaria Control

Respondents identified a range of community engagement strategies employed in Centenary District's malaria control programmes. Health education and awareness campaigns were the most commonly reported strategy (50%), followed by ITN distribution (20%), environmental clean-up activities (15%) and community mobilisation by local leaders (10%). Indoor Residual Spraying (IRS) was cited by only 10% of respondents, suggesting significant gaps in the reach and uptake of this intervention. Emerging digital tools, including WhatsApp groups and mobile reporting applications, were identified as promising complementary approaches by key informants. 

The District Nursing Officer highlighted the breadth of current approaches: "Currently, we are using door-todoor campaigns, health education sessions, school-based awareness programmes and community meetings (barazas) to sensitise people." The District Environmental Health Officer affirmed the multi-stakeholder character of these efforts: "Various strategies are being implemented, for example, household sprays in partnership with VHWs, traditional leaders, faith-based organisations and NGOs such as PSI and the Ministry of Health." 

These findings are consistent with WHO [1], recommendations that effective malaria control requires a diversified portfolio of community engagement strategies tailored to local contexts. The low uptake of IRS (10%) aligns with Dube et al. [22], who found widespread cultural resistance to indoor spraying in rural Zimbabwe, driven by misconceptions about chemical safety and beliefs linking malaria to spiritual causes.

Perceived Effectiveness of Community Engagement Strategies

Ninety percent of respondents perceived the community engagement strategies employed in Centenary District as effective, with 60% rating them "very effective" and 30% "effective". Table 2 presents perceptions of changes in malaria prevention practices observed following community engagement activities.

Fifty percent of respondents observed moderate improvements in malaria preventive behaviours, including increased net use, improved environmental hygiene and more timely treatment-seeking.

Table 2: Observed Changes in Malaria Prevention Practices

Thirty percent reported significant improvements, while 10% observed no change or worsening practices, particularly in areas characterised by strong cultural resistance or logistical inaccessibility. The most impactful community-led initiatives were health education campaigns (55%), followed by ITN distribution (17%), environmental management (13%), CHW-led initiatives (10%) and community volunteer training (5%). These findings resonate with Ssewanyana et al. [23], who systematically reviewed evidence from 22 sub-Saharan African studies and concluded that community-based education produces the most consistent improvements in malaria prevention behaviours. The Executive Officer for Health noted that community-led initiatives "fostered ownership among communities and resulted in improved environmental sanitation, increased use of nets and prompt treatment-seeking behaviour."

Community Understanding and Treatment-Seeking Behaviour

Despite high perceived effectiveness of strategies, 55% of respondents reported poor community understanding of malaria prevention efforts, while only 15% indicated clear community understanding. This gap between programme delivery and community comprehension underscores the importance of culturally adapted health communication. As the District Environmental Health Officer stated: "Messages such as 'malaria is deadly seek treatment within 24 hours of fever onset' have proven effective when disseminated through community gatherings and radio." 

Regarding treatment-seeking behaviour, 70% of respondents agreed that community engagement activities strongly encouraged timely treatment-seeking, while 20% reported moderate encouragement. Table 3 summarises the key determinants of treatment-seeking behaviour reported by respondents.

Affordability was the foremost determinant of treatment-seeking behaviour (30%), followed by community health education (20%) and facility availability (15%). These findings are consistent with Matinhure et al. [17], who identified financial barriers and distance to health facilities as the most significant obstacles to timely malaria treatment in rural Zimbabwe. The District Nursing Officer reported observable behavioural change: "In the past, they waited 2–3 days; these days, most people try to get care within the day or 24 hours." The District Environmental Health Officer corroborated this with ward-level evidence: "In Ward 13, after a campaign run in schools, clinic attendance for suspected malaria cases increased by 40% in one month."

Table 3: Determinants of Treatment-Seeking Behaviour for Malaria 

Community Level Involvement 

Table 4 presents respondents' ratings of the level of community involvement in malaria prevention activities.

Fifty percent of respondents rated community involvement as very high, while 24% indicated moderate involvement. Sixteen percent noted minimal involvement and 10% reported no community participation. The high levels of reported involvement align with findings from Afolabi et al. [24], who found that community ownership cultivated through consistent CHW engagement and leadership mobilisation is among the most reliable predictors of sustained behaviour change in malaria-endemic African settings.

Table 4: Level of Community Involvement in Malaria Prevention

Challenges and Barriers to Implementation

Several barriers to effective implementation were identified. Limited access to health services was the most commonly reported challenge (30%), followed by cultural and traditional beliefs (25%), lack of community awareness (20%), poor road infrastructure (9%), resistance to malaria prevention tools (8%), high cost of services (5%) and insufficient programme funding (2%). 

Cultural beliefs attributing malaria to spiritual causes or discouraging ITN use during hot weather were recurring themes in key informant accounts. The Executive Officer for Health noted: "Misconceptions about IRS, discomfort with sleeping under nets in hot weather and cultural beliefs that malaria is caused by bad spirits" represent persistent barriers requiring sustained, respectful community dialogue. Resistance to IRS was further compounded by misinformation about chemical safety, a finding consistent with Dube et al. [22] and Chikowore et al. [15]. 

Logistical constraints-including supply chain disruptions for nets, insufficient storage capacity and inaccessibility during the rainy season also impeded programme delivery. The Executive Officer for Health identified the need to "preposition supplies before the onset of the rainy season" as a critical operational priority. CHW effectiveness was further constrained by lack of incentives, inadequate training and limited transport, with most CHWs functioning as unpaid volunteers at risk of burnout [14,25].

Seventy percent of respondents rated CHWs as very important in addressing implementation barriers, while 20% rated them as important.This near-universal endorsement of CHWs reflects their irreplaceable role as culturally embedded intermediaries between formal health institutions and marginalised rural communities, consistent with evidence from Tambo et al. [3] and Mubita et al. [4].

Table 5: Perceived Importance of CHWs in Overcoming Barriers

This study demonstrates that community engagement is a vital and broadly effective strategy for promoting malaria prevention and treatment practices in Centenary District, Mashonaland Central Province, Zimbabwe. Health education campaigns, ITN distribution and environmental management, delivered primarily through CHWs and community mobilisation by local leaders, have produced measurable improvements in malaria preventive behaviours and treatment-seeking timeliness. CHWs, who constituted 50% of respondents, are recognised as indispensable to community malaria control in this rural setting. 

Nevertheless, significant challenges remain. Poor community understanding of malaria prevention efforts, entrenched cultural beliefs, affordability barriers, logistical constraints and inadequate support for CHWs continue to limit programme reach and sustainability. The persistence of low IRS uptake (10%) and the 10% of respondents reporting no improvement or worsening practices signal the need for more targeted, culturally sensitive and community-owned approaches. The strong correlation between community engagement intensity and improved malaria outcomes reinforces the conclusion that investing in community-level capacity is essential to achieving the targets set in Zimbabwe's National Malaria Strategic Plan.

Recommendations

Based on the study findings, the following recommendations are advanced:

• Strengthen and Incentivise CHWs: CHWs should receive regular refresher training, transport support (such as bicycles), digital data collection tools and meaningful financial incentives or stipends to reduce attrition and improve performance [14]

• Enhance Culturally Tailored Health Communication: Health education campaigns must be delivered in local languages, using culturally relevant metaphors and trusted community messengers including traditional leaders and faith-based organisations, to address misconceptions about IRS and ITN use [18,21]

• Deepen Local Leadership Engagement: Traditional leaders, village heads and councillors should be formally integrated into malaria programme planning, implementation and monitoring as community champions, particularly in areas resistant to biomedical interventions [3,15]

• Expand Access to Healthcare Services: Mobile outreach clinics and community-based case management should be scaled up in hard-to-reach areas to reduce distances to treatment and address financial barriers, complemented by community referral systems coordinated through CHWs [17]

• Leverage Digital and Multi-Media Platforms: Mobile SMS reminders, community radio broadcasts, WhatsApp group messaging and community malaria scorecards should be adopted to reinforce health messages, support real-time reporting and sustain community engagement between physical campaigns [16]

• Strengthen Multi-Sectoral Coordination: Joint malaria planning sessions, shared M&E frameworks and community feedback mechanisms should be institutionalised among the MOHCC, NGOs, district councils, schools and faith institutions to eliminate duplication, align resources and sustain community ownership of malaria control efforts [2].

Areas for Future Research

Future research should examine the long-term impact of community engagement interventions on malaria incidence and mortality trends in Centenary District through longitudinal study designs. The role of digital health innovations, including mobile malaria surveillance tools and community health scorecards, in improving data quality and real-time decision-making warrants dedicated investigation. Additionally, gender responsive malaria programming particularly the role of women's groups and mother-to-mother peer education in shaping household malaria practices represents an underexplored area in the Zimbabwean context.

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