Use of statistical modelling and analyses of malaria rapid diagnostic test outcome in Ethiopia.
The transmission of malaria is among the leading public health problems in Ethiopia. From the total area of Ethiopia, more than 75% is malarious. Identifying the infectiousness of malaria by socio-economic, demographic and geographic risk factors based on the malaria rapid diagnosis test (RDT) survey results has several advantages for planning, monitoring and controlling, and eventual malaria eradication effort. Such a study requires thorough understanding of the diseases process and associated factors. However such studies are limited. Therefore, the aim of this study was to use different statistical tools suitable to identify socioeconomic, demographic and geographic risk factors of malaria based on the malaria rapid diagnosis test (RDT) survey results in Ethiopia. A total of 224 clusters of about 25 households were selected from the Amhara, Oromiya and Southern Nation Nationalities and People (SNNP) regions of Ethiopia. Accordingly, a number of binary response statistical analysis models were used. Multiple correspondence analysis was carried out to identify the association among socioeconomic, demographic and geographic factors. Moreover a number of binary response models such as survey logistic, GLMM, GLMM with spatial correlation, joint models and semi-parametric models were applied. To test and investigate how well the observed malaria RDT result, use of mosquito nets and use of indoor residual spray data fit the expectations of the model, Rasch model was used. The fitted models have their own strengths and weaknesses. Application of these models was carried out by analysing data on malaria RDT result. The data used in this study, which was conducted from December 2006 to January 2007 by The Carter Center, is from baseline malaria indicator survey in Amhara, Oromiya and Southern Nation Nationalities and People (SNNP) regions of Ethiopia. The correspondence analysis and survey logistic regression model was used to identify predictors which affect malaria RDT results. The effect of identified socioeconomic, demographic and geographic factors were subsequently explored by fitting a generalized linear mixed model (GLMM), i.e., to assess the covariance structures of the random components (to assess the association structure of the data). To examine whether the data displayed any spatial autocorrelation, i.e., whether surveys that are near in space have malaria prevalence or incidence that is similar to the surveys that are far apart, spatial statistics analysis was performed. This was done by introducing spatial autocorrelation structure in GLMM. Moreover, the customary two variables joint modelling approach was extended to three variables joint effect by exploring the joint effect of malaria RDT result, use of mosquito nets and indoor residual spray in the last twelve months. Assessing the association between these outcomes was also of interest. Furthermore, the relationships between the response and some confounding covariates may have unknown functional form. This led to proposing the use of semiparametric additive models which are less restrictive in their specification. Therefore, generalized additive mixed models were used to model the effect of age, family size, number of rooms per person, number of nets per person, altitude and number of months the room sprayed nonparametrically. The result from the study suggests that with the correct use of mosquito nets, indoor residual spraying and other preventative measures, coupled with factors such as the number of rooms in a house, are associated with a decrease in the incidence of malaria as determined by the RDT. However, the study also suggests that the poor are less likely to use these preventative measures to effectively counteract the spread of malaria. In order to determine whether or not the limited number of respondents had undue influence on the malaria RDT result, a Rasch model was used. The result shows that none of the responses had such influences. Therefore, application of the Rasch model has supported the viability of the total sixteen (socio-economic, demographic and geographic) items for measuring malaria RDT result, use of indoor residual spray and use of mosquito nets. From the analysis it can be seen that the scale shows high reliability. Hence, the result from Rasch model supports the analysis carried out in previous models.