Background <p>Malaria remains a major public health problem in Ethiopia, particularly in endemic areas such as Pawe district. Accurate and timely diagnosis is essential for effective case management and control. This study aimed to determine the prevalence of malaria, evaluate the diagnostic performance of malaria rapid diagnostic tests (mRDTs) against light microscopy, and assess associations between socio-demographic factors and malaria infection among febrile patients at Pawe General Hospital.</p> Methods <p>A hospital-based cross-sectional study was conducted from November to December 2022 among 422 febrile patients suspected of malaria. Socio-demographic data were collected using a structured questionnaire. Capillary blood samples were examined by Giemsa-stained thick and thin smears (microscopy) and Bioline™ Malaria Ag Pf/Pv mRDTs. Data were analyzed using SPSS version 26; logistic regression assessed associations between socio-demographic variables and malaria infection. Diagnostic performance indices of mRDT (sensitivity, specificity, positive predictive value, and negative predictive value) and Cohen’s kappa were calculated using microscopy as the reference standard.</p> Results <p>The overall prevalence of malaria by microscopy was 27.0% (114/422). <i>Plasmodium falciparum</i> accounted for 84.2%, <i>P. vivax</i> for 7.9%, and mixed infections for 7.9%. In the multivariable analysis, male participants were nearly twice as likely to be infected with malaria compared to females (AOR = 1.88; 95% CI: 1.16–3.04; <i>p</i> = 0.011). Participants from households with five or more family members had over two times higher odds of malaria infection than those from smaller families (AOR = 2.19; 95% CI: 1.36–3.54; <i>p</i> = 0.001). The mRDT showed 99.1% sensitivity, 99.3% specificity, 98.3% positive predictive value, and 99.7% negative predictive value, with almost perfect agreement with microscopy (κ = 0.98).</p> Conclusion <p>Malaria remains a significant health concern in the study area. The Bioline™ mRDT demonstrated diagnostic accuracy comparable to microscopy and can be reliably used for routine malaria diagnosis in resource-limited settings. Male sex and large family size were identified as significant socio-demographic risk factors for malaria infection. Strengthening preventive measures targeting high-risk groups is recommended, while microscopy remains valuable for species confirmation and quality assurance.</p> Clinical trial <p>Not applicable.</p>