Exploring the Contextual Factors Influencing the Implementation and Effectiveness of Community Health Worker–Led Malaria Community Case Management in Kailahun District, Sierra Leone

Abstract:

Background: CHW-led community malaria case management (CCMm) extends services to rural, hard-to-reach communities in Kailahun District, Sierra Leone, where the malaria burden is heaviest; yet the same standardised intervention produces different outcomes across chiefdoms. This paper asks how contextual conditions enable or block the mechanisms through which CHWs produce outcomes. Methods: A qualitative realist evaluation using the Context–Mechanism–Outcome framework drew on six key informant interviews, three CHW contextual interviews, and six focus group discussions (58 caregivers) and analyzed them thematically with realist-informed coding and text-network analysis. Results: Contextual influences spanned nine domains: geographic, health-system, socio-cultural, gender, economic, governance, programmatic, historical, and market. Traditional authority engagement and geographic accessibility were decisive across every tier, and the same conditions acted as facilitators when present and barriers when absent. Conclusion: Context is constitutive, not background; policy should stabilise a small set of conditions—above all supply continuity and traditional authority engagement—that determine whether its mechanisms fire.