Climate blind spots in malaria control: frontline perspectives on climate adaptation and malaria control in Zambia

Climate change is increasingly recognised as a significant barrier to malaria elimination, particularly in low- and middle-income countries. This study explored frontline perspectives of healthcare workers and community-based volunteers on climate change and how malaria control programmes are responding to these changes in Zambia. A cross-sectional qualitative study was conducted in 20 districts representing higher- and lower-malaria burden settings in Zambia. Nine key informant interviews and fourteen focus group discussions were conducted with 64 healthcare workers and community-based volunteers. Data were analysed thematically using ATLAS.ti. Participants reported that flooding, drought, deforestation, and shifting rainfall patterns were altering malaria transmission and increasing mosquito breeding sites. Climate-related disruptions, poor road access during floods and competing health priorities, including cholera outbreaks and COVID-19, were perceived to hinder malaria prevention and case management. Although participants recognised climate-related malaria risks, proposed responses remained largely focused on strengthening existing interventions such as indoor residual spraying and insecticide-treated nets, with limited reference to broader climate adaptation measures or national climate policies. Participants also identified barriers, including vector resistance, diagnostic challenges and supply chain disruptions. Frontline perspectives highlight substantial climate-related challenges to sustaining malaria control in Zambia. While healthcare workers and community-based volunteers recognised that climate variability influences malaria transmission, this awareness was not consistently accompanied by consideration of how malaria programmes may need to adapt. Strengthening climate-health competencies, improving policy dissemination, and integrating climate considerations into routine malaria planning and decision-making may help support climate-adaptive malaria control and sustain progress towards elimination.

The World Health Organisation (WHO) recognises climate change as the biggest health threat to humanity (1, 2). Its impacts are particularly severe in low- and middle-income countries (LMICs), where vulnerability to vector- and waterborne diseases is high (3). Malaria transmission seasons are expected to lengthen and intensify as climatic conditions become more favourable for transmission (3–5). The health impacts of climate-sensitive malaria transmission are expected to be compounded by population growth, food insecurity associated with climate sensitive crop failures, existing disease burdens and weaknesses in public health infrastructure.

Malaria remains one of the world’s deadliest infectious diseases, with cases and deaths continuing to rise despite substantial investment in control efforts, threatening progress towards the 2030 Malaria Elimination goals (6, 7). In 2023, an estimated 263 million cases and 597,000 deaths were reported, up from 252 million cases in 2022 (8). Sub-Saharan Africa (SSA) accounted for 94% of cases and 95% of all deaths globally. WHO recommends tailored, data-driven approaches, including indoor residual spraying (IRS), insecticide-treated nets (ITNs), chemoprophylaxis, enhanced surveillance, and malaria vaccination for children under five (7, 9). More than 30 endemic SSA countries, including Zambia, have adopted these interventions (9).

Climate change is increasingly recognised as a major barrier to malaria elimination (6, 9). Under worst-case climate scenarios, an additional 75.9 million people in Eastern and Southern Africa could be exposed to year-round malaria transmission by the year 2080, with the greatest increase in risk occurring in Eastern Africa (10). Climate influences malaria transmission through multiple pathways, affecting mosquito survival, parasite development, vector behaviour and the environmental conditions required for transmission (11, 12). These relationships are often complex and may vary across ecological settings making future transmission patterns difficult to predict (12). Rising temperatures and changing rainfall patterns and climatic events such as El Niño, and environmental factors including humidity, aridity and land-use change, can all influence malaria transmission dynamics (11–13).

As evidence accumulates that climate variability is altering the timing, intensity, and geographic distribution of malaria risk (14), understanding how frontline healthcare workers and community-based volunteers perceive and respond to these changes has become increasingly important. However, little is known about whether frontline personnel understand the implications of climate variability for malaria transmission or feel adequately prepared to support climate-responsive malaria control efforts.

Despite implementation of the revised Malaria Elimination Strategy in 2021, malaria mortality in Zambia increased by 3.2% between 2020 to 2022 (15). Malaria transmission remains highly seasonal, typically peaking between January and April during the rainy season (9, 14). However, increasing evidence suggests that transmission patterns are also influenced by climatic variability, including changes in rainfall, humidity, temperature and land use (10, 16, 17). These shifts may have important implications for the timing and effectiveness of malaria control interventions.

WHO recommends climate-resilient and climate-informed health systems as a cornerstone of effective disease control and universal health coverage (18). Achieving this requires a health workforce that is equipped to recognise and respond to climate-sensitive health threats. However, evidence suggests that while healthcare workers generally acknowledge the health impacts of climate change, important gaps remain in their understanding of adaptation and mitigation strategies (18, 19). These gaps may undermine malaria elimination efforts as climate-related changes in transmission become increasingly pronounced.

This study explored frontline health workers’ and community-based volunteers’ (CBVs) perceptions of how climate variability influences malaria transmission and the capacity malaria control systems to respond to these changes in Zambia. These groups were selected because they operate at the interface between communities, surveillance systems, and malaria programmes. Through their roles in case management, health promotion, surveillance, and community engagement, they are often among the first to observe changes in malaria patterns and operational challenges. Their perspectives therefore provide valuable insights into both climate-related malaria transmission and the preparedness of malaria control systems to respond.

Study site

This study was conducted in Zambia, a landlocked sub-Saharan African country with a surface area of 752,612 km² and a population of 19.6 million according to the 2022 Census (20). Zambia is divided into 10 provinces and 116 districts and experiences marked climatic variation, with higher rainfall generally occurring in the northern regions. The rainy season typically extends from October to April, although recent years have been characterised by periods of flooding associated with El Niño events followed by prolonged droughts (21). Malaria remains endemic throughout the country, although transmission intensity varies substantially across provinces and districts (22). Lusaka and Southern provinces generally report the lowest malaria burden, while. Plasmodium falciparum accounts for approximately 90% of malaria cases nationally (22, 23).

To capture this heterogeneity, district selection was informed by routine Health Management Information System (HMIS) malaria incidence data and aimed to include both higher- and lower-burden settings within each province. In total, 20 districts were selected across Zambia’s 10 provinces (Figure 1). Details of the district selection process, selected districts, and malaria incidence data used to guide site selection are provided in Supplementary Table 1 and Supplementary Figure 1.

Study design

A cross-sectional qualitative descriptive study was conducted using key informant interviews (KII) and focus group discussions (FGD) among frontline health workers and community-based volunteers. The study explored perceptions of how climate variability influences malaria transmission and the capacity of malaria control systems to respond to these changes. This qualitative component was embedded within a broader mixed-methods study examining climate related malaria transmission in Zambia.

Data were collected from August to October 2023. KII and FGD were conducted across 20 selected districts representing higher- and lower- burden malaria transmission settings (Figure 1). The use of both KIIs and FGD enabled exploration of individual perspectives from decision-makers and technical officers alongside shared experiences and operational realities among frontline personnel.

Districts were selected to maximise variation in malaria transmission settings rather than to support formal comparisons between high- and low-burden districts. During analysis, KII and FGD transcripts were initially reviewed separately to identify areas of convergence and divergence before being integrated into a common thematic framework, as substantial thematic overlap was observed across data sources.

Study population

Participants included frontline health professionals and community-based volunteers involved in malaria prevention, diagnosis, treatment, surveillance and community engagement activities in selected districts. This mix of cadres ensured representation from both technical and community-facing components of malaria control.

Sampling and data collection procedure

The study was implemented across all 10 provinces of Zambia. The district selection process is described in Supplementary Table 1 and Supplementary Figure 1. To capture perspectives across the health system, data were collected at the facility or district levels. Purposive sampling was used to recruit participants with at least three years of experience in malaria control programmes or involvement in climate-related public health activities. Key Informant Interviews (KII) were conducted with district level informants such as the District Health Directors or Public Health Specialists, and at facility level the Malaria Program Officer.

KIIs lasted approximately 45 minutes in person. FGDs with four to seven malaria programme staff, lasted about 90 minutes to ensure full participation. To minimise the influence of professional hierarchy, FGDs were conducted within similar occupational groups wherever feasible, and facilitators actively encouraged participation from all members. Moderators used probing techniques to ensure that quieter participants and community-based volunteers were given opportunities to contribute alongside more senior staff.

KII used structured, open-ended guides conducted in English. The interview guides covered four broad domains: (i) perceptions of climate variability and environmental change; (ii) perceived effects of climate variability on malaria transmission; (iii) malaria control interventions and operational challenges; and (iv) opportunities for climate adaptation and health system strengthening. The same core domains were explored across KIIs and FGDs to facilitate comparison across participant groups. The interview guides are provided in Supplementary Table 2: Interview Guide.

Data analysis

Data captured using digital recorders during KII and FGDs were transcribed verbatim by trained transcribers, including nonverbal cues. Transcripts were proofread against the audio to ensure accuracy. The participants’ names were omitted. Investigators (NM and JM) audited transcripts by cross-checking with recordings to preserve meaning. Minor edits improved readability, correcting misheard words, vernacular phrasing, and grammar.

Qualitative data were analysed using thematic analysis. A coding framework was developed based on the study objectives and interview guide domains, including climate change awareness, malaria transmission, capacity of health system, malaria control challenges, and adaptation strategies. The framework was refined iteratively during analysis as additional concepts were identified. The final codebook is provided in Supplementary Table 3. Following nine KIIs and fourteen FGDs, no new concepts were identified in subsequent interviews, and data collection was therefore concluded.

Analysis was conducted by two researchers (JM and NM). JM, who has extensive experience in qualitative research methods, led the thematic analysis, while NM contributed expertise in infectious diseases, malaria epidemiology, and climate-related health threats. Transcripts were independently reviewed and coded, with coding differences discussed and resolved through consensus. The coding framework was refined iteratively throughout the analysis, with codes merged, expanded, or reorganised as understanding of the data developed. Themes were developed through an iterative process of coding, interpretation and discussion between the researchers consistent with recommendations for reflexive thematic analysis reporting (24).

Transcripts were imported into ATLAS.ti version 23 for review. Each transcript was analysed line by line, noting relevant statements. The interviewers’ summary notes were also reviewed to capture nonverbal cues not evident in recordings. Results are presented as themes and subthemes supported by illustrative participant quotations.

Ethical considerations

Ethical approval was obtained from the Lusaka Apex Medical University IRB and the National Health Research Authority (Ref No: NHRA000013/23/08/2023). Informed consent was obtained from all participants, who were explicitly informed of their right to withdraw from the study at any time. Interview location and timing-maintained participants’ privacy and confidentiality. After the manuscript was completed, voice recordings and transcripts were securely stored on the researchers’ computer with password protection.

Context within which malaria control strategies are delivered

A total of 64 individuals participated in the interviews, comprising 29 Community Based Volunteers and 35 district-level health personnel. 17.94% were aged 20-29, 41.03% were 30-39, 20.51% were 40-49, and 20.51% were 50 or older. Participants had between three and seventeen years of experience in their current roles. All participating facilities were part of Zambia’s national malaria control program. The District Health Office, led by the District Health Director, oversees health facilities and public health services. Malaria program officers, often environmental health or surveillance officers, handle supervision, monitoring, training, and coordination. Clinical officers, nurses, and doctors managed patient care, while CBVs supported Integrated Community Case Management (ICCM) for early diagnosis and treatment. District program officers meet quarterly to review progress and challenges. Table 1 summarises participant professions, with EHOs and CBVs making up the largest group.

Factors associated with knowledge about climate change

All respondents were knowledgeable about malaria control, given their roles in patient management or the national malaria program. Awareness of climate change was reported across all focus group discussions, although the depth of understanding varied considerably among participants. However, participants varied considerably in their understanding of how climate variability influences malaria transmission and how malaria programs may need to respond. Self-reported perceptions of climate change’s impact on malaria incidence are summarised in Table 2 and further explored in the narrative.

Understanding of climate change and malaria transmission

Healthcare workers had varying awareness of climate change’s impact on malaria and other infectious diseases. Participants demonstrated varying levels of understanding of how climatic factors, such as humidity, rainfall variability and extreme heat influence malaria transmission.

Some participants linked climate change to human-environment interactions that could increase malaria endemicity, as illustrated by these quotes from district malaria control officers.

“Malaria incidence is strongly influenced by climate. For instance, if the rains begin earlier in October, we see a rise in cases starting from then rather than in December. Additionally, during hot periods, we experience a surge in diarrheal cases because as the water table drops, people start drawing water from streams and shallow wells, which also serve as mosquito breeding sites.” – Male Malaria Program Officer, FGD3.

Most participants were unfamiliar with national climate adaptation policies and rarely referred to climate-adaptive malaria control strategies.

Participants reported varying levels of confidence in their understanding of climate change, with differing perspectives observed across professional cadres and levels of experience. In one FGD a response to the question “How much do you know about this topic of climate change?” affirms “Very much. I did my bachelor’s in environmental studies.” (Male EHO in FGD7) whilst in a different FGD the respondent acknowledged “ I do not know much, I will rate myself at 30%.”- Female EHO, FGD 3.

Observed influence of climate change on health

Participants reported increased malaria cases during both periods of flooding and droughts. They described challenges such as misaligned timing of indoor residual spraying (IRS), migration to fishing or farming camps after IRS and reduced access to antenatal IPT during floods, for example:

“IRS isn’t very effective due to delayed applications during the rains. Mushindamo also has many impassable areas because of poor road networks, so not everyone is reached during ITN distribution. Additionally, during floods, pregnant women can’t visit the clinic for IPT.” – Male EHT, FGD 5.

Other participants linked climate change to expanding mosquito breeding sites and to indirect pathways, such as food insecurity, which contributes to anaemia and severe malaria.

“Recently, there’s been a greater need for spraying interventions due to the increase in breeding sites around the district.” – Male EHT, KII2.

Contextual factors influencing the effectiveness of malaria control strategies

Participants described resource constraints, competing disease outbreaks, and disruptions associated with climate related events as important challenges to malaria control, for example:

“As a surveillance officer, we didn’t focus much on malaria during COVID because we were overwhelmed.” – Male EHT, FGD 1.

Workers emphasised the need for climate change interventions that integrate with existing programmes rather than overwhelm them.

Proposed mitigation and adaptation measures

Respondents identified human-environment interactions, such as farming, deforestation, and urbanisation, as key contributors to both climate change and increased malaria transmission. They recommended community-based measures such as reforestation and conservation farming, improved drainage, and the promotion of green energy.

“In rural areas, people continue cutting trees as it’s their main source of income, especially for charcoal production. Without electricity, they have no alternatives for cooking and survival.” – Male COG, FGD 2.

However, most participants focused on strengthening existing malaria tools such as IRS, ITNs, larviciding rather than proposing broader climate-responsive measures such as climate informed surveillance, workforce preparedness or early warning systems.

“It’s our job as community workers to help sensitize the community on climate change and malaria.” – Female CBV, FGD 6.

“ Education alone won ’ t be enough; we need ITNs, repellents, larviciding, and mass anti-malaria drug administration twice a year. ” – Male EHT, KII 4.

No participants mentioned malaria vaccination when discussing responses to climate related malaria challenges. Similarly, discussions focused primarily on community-based and vector control interventions, with limited reference to facility-level adaptation measures or broader health system preparedness strategies. Across themes, participants generally recognised that climatic conditions influence malaria transmission, although discussions of potential responses were largely centred on existing malaria control interventions.

This study explored healthcare workers’ (HCWs) and community-based volunteers’ (CBVs) perceptions of how climate variability affects malaria transmission and the capacity of malaria control systems to respond to these changes. The findings offer valuable insights into existing knowledge, operational challenges, and opportunities for strengthening climate-adaptive malaria control strategies in Zambia.

Consistent with global assessments, participants recognised that climate variability is increasingly influencing malaria dynamics in Zambia (25). They demonstrated strong knowledge of core malaria countermeasures but less clarity and confidence in explaining the mechanisms through which climate change affects malaria transmission. This mirrors gaps that are identified in the National Adaptation Plan (21) and similar studies across sub-Saharan Africa, where knowledge of climate-health linkages is uneven despite high frontline exposure (16, 18, 25–27).

Participants perceived recent reductions in malaria burden to be associated with decentralised diagnosis and treatment, particularly the expanded role of CBVs in ICCM, aligning with the National Malaria Elimination Strategic Plan (NMESP) 2022-2026 (16). However, participants also reported that malaria incidence has plateaued, attributing this partly to behavioural and environmental barriers such as non-use of nets during hot seasons, deforestation and reliance on shallow wells for household water use, as has been seen elsewhere (16, 28). They also noted increasingly unpredictable climate events, including early rains, extreme heat, flooding, and prolonged droughts, as factors influencing malaria transmission. These observations are consistent with ecological system analyses from the region, which show the impact of land-use changes, humidity, and rainfall patterns on vector breeding (11, 29, 30).

A key finding of this study was that participants generally recognised climate variability as an important influence on malaria transmission. However, discussions of potential responses remained largely focused on established malaria interventions and community-level behavioural approaches such as IRS, ITNs and case management. Consideration of broader health-system adaptation measures such as climate-informed surveillance, early warning systems, workforce preparedness, logistics and supply chain management, or other health-system responses to increasing climatic events, was limited. Few participants referenced national climate adaptation policies (21), highlighting a disconnect between national planning and frontline practice. While awareness of climate-related risks was widespread, climate considerations were not routinely translated into discussions of program adaption or frontline decision making. This finding extends previous studies that have documented climate change awareness among HCW (26, 27) by showing that awareness does not necessarily translate into consideration of how malaria programmes should adapt to changing transmission dynamics. As climate variability becomes an increasingly important driver of malaria transmission, awareness alone is unlikely to be sufficient. Malaria programmes may increasingly require adaptation-oriented approaches that incorporate climatic information into planning, surveillance, workforce preparedness and intervention delivery (28, 31). This climate blind spot, therefore, was not a lack of awareness of climate change, but limited consideration of adaptation-oriented malaria control strategies.

Participants primarily proposed strengthening existing malaria control measures, including vector control, reforestation, conservation farming and improving urban drainage. While these approaches may contribute to malaria control, they largely focused on community level responses rather than broader health-system adaptation to a changing climate (2, 14). Participants also identified several factors that undermine malaria control effectiveness, including resource diversion during the COVID-19 pandemic, the increased burden of other climate-sensitive infectious diseases such as cholera and arboviruses, supply chain disruptions, vector resistance, diagnostic challenges and the mobility of farming and fishing communities. Together, these findings suggest that frontline personnel are aware of many of the environmental and operational challenges affecting malaria control but may require additional support to translate this awareness into climate-adaptive malaria strategies. Strengthening climate-health competencies among HCW and CBV, alongside development of climate-adaptive malaria planning tools and training curricular may help bridge this gap and support malaria elimination efforts in Zambia and similar settings (18, 25–29).

Although malaria vaccination was not yet part of routine malaria control in Zambia at the time of data collection (32), its absence from broader discussions of future responses is noteworthy. This likely reflects its limited operational relevance at the time rather than a lack of awareness among frontline personnel. Nevertheless, the finding highlights how emerging malaria control tools had not yet been incorporated into broader discussions of climate adaptation and programme planning, unlike in countries like Madagascar where vaccinations are done prior to cyclones (31). This observation is particularly relevant as growing evidence suggests that climate variability is reshaping malaria transmission patterns across Zambia and the wider region (12, 17, 33–36). As countries introduce malaria vaccines, deployment strategies may need to consider local epidemiological and environmental conditions rather than relying solely on traditional assumptions about seasonality (31). Malaria vaccination therefore represents not only an additional malaria control tool, but also a potential component of climate-adaptive malaria control programmes (36, 37).

Ultimately, the findings highlight the need to strengthen the capacity of healthcare workers and community-based volunteers to translate awareness of climate-related risks into practical malaria control responses. The climate blind spot identified in this study was not a lack of awareness that climate variability influences malaria transmission. Rather, it was the limited consideration of how malaria programmes themselves may need to adapt in response. Strengthening climate-health competencies, including the interpretation of climatic information, use of early warning systems, and integration of climate considerations into routine malaria planning, may help bridge this gap (35, 38). Investment in meteorological surveillance and stronger links between climate and health information systems could further support climate-adaptive malaria control (8, 14, 38).

This study has several strengths. It draws on rich, diverse perspectives from HCWs across all provinces, capturing a wide range of professional experiences. The qualitative methods facilitated in-depth exploration of climate and health linkages, yielding insights with direct operational implications. By examining not only awareness of climate change but also how climate considerations are incorporated into malaria control thinking and decision making, the study provides practical insights for strengthening climate adaptation within malaria programmes. The findings may also inform adaptation planning for other climate-sensitive infectious diseases, which are expected to rise (4, 28, 39, 40).

There are limitations. Data were collected before the severe drought of 2024, the worst in Zambia’s recent history, as evidenced by the National Drought Emergency Response Plan (41), which may have further heightened the relevance of climate-health linkages. Nevertheless, the study provides valuable baseline insights from frontline perceptions before the 2024 drought and captures views formed during a period of increasing climatic variability. Several measures were employed to enhance analytical rigour, including iterative coding, comparison of interpretations between analysts, review of field notes alongside transcripts, and regular discussions to refine themes and challenge assumptions.

Climate change is reshaping malaria transmission patterns in Zambia, and frontline healthcare workers and community-based volunteers are already observing its effects. While participants demonstrated strong knowledge of malaria control and recognised that climate variability influences transmission, this awareness was not consistently accompanied by consideration of how malaria programmes may need to adapt. The climate blind spot identified in this study was therefore not a lack of awareness of climate change, but a gap between recognising climate-related risks and translating that knowledge into adaptation-oriented malaria control strategies.

Addressing this gap will require more than awareness raising alone. Strengthening climate-health competencies among frontline personnel, improving dissemination of climate adaptation policies, enhancing cross-sectoral collaboration, and investing in climate-informed surveillance and early warning systems will be essential. As climatic conditions become increasingly more important determinants of malaria risk; front line personnel will need the skills and tools to incorporate climate considerations into routine malaria planning and decision-making. Ensuring that emerging interventions, including malaria vaccination, are integrated within broader climate-adaptive malaria control strategies may help strengthen programme resilience and sustain progress towards malaria control and elimination.