International Journal of TROPICAL DISEASE & Health

Introduction: Malaria remains a leading cause of under-five morbidity and mortality in sub-Saharan Africa. In Nigeria, despite effective artemisinin-based combination therapy (ACT), timely initiation, adherence, and referral for childhood malaria are suboptimal, particularly in rural settings. This study assessed the effect of structured caregiver training on these outcomes in rural communities of Rivers State, Nigeria.

Methods: A quasi-experimental study with pre- and post-intervention assessments and a control group was conducted. A total of 376 caregivers (188 intervention; 188 control) were enrolled. The intervention comprised structured training on symptom recognition, correct ACT dosing, and danger signs requiring referral. Primary outcomes were timely ACT initiation (≤24 hours), complete adherence, and timely referral. Difference-in-differences (DiD) analysis estimated net intervention effects, and Cohen's h quantified effect sizes.

Results: Baseline characteristics were comparable. Timely ACT initiation increased from 38.3% to 65.4% in the intervention group versus 36.7% to 41.1% in controls (DiD = +22.7 percentage points; p < 0.001). Adherence improved from 44.1% to 71.4% versus 46.8% to 51.1% (DiD = +23.0; p < 0.001). Timely referral improved from 52.7% to 78.6% versus 54.8% to 59.4% (DiD = +21.2; p < 0.001). Effect sizes were moderate to large (Cohen's h: 0.41–0.63). Multivariate analysis confirmed the intervention independently predicted all outcomes (AOR: 2.36–3.12; p ≤ 0.001).

Conclusion: Structured caregiver training significantly improved timely ACT initiation, adherence, and referral for childhood malaria in rural Nigeria. Integrating such interventions into primary healthcare is recommended for high-burden settings.