Reflections on the ethics of participatory visual methods to engage communities in global health research

Culturally responsive research ethics: How the socio-ethical norms of Arr-nar/Kreng-jai inform research participation at the Thai-Myanmar border

Despite advances, international research ethics guidelines still tend to consist of high-level ethical principles reflecting residual influence from North American and European traditions of ethics. Local ethics committees and community advisory boards can offer more culturally-sensitive approaches to training but most institutions lack substantive practical ethics guidance to engage rich moral understandings in day-to-day research practice in diverse cultural contexts. To address this gap, we conducted an international series of qualitative research ethics case studies, linked prospectively to active research programs in diverse settings. Here, we share findings from two case studies with a research team working on malaria and hepatitis B prevention with pregnant women in clinics serving migrants along the Thai-Myanmar border. In this sociocultural ethical analysis, we consider how core ethical requirements of voluntary participation, provision of fair benefits, and understandings of research risks and burdens are shaped, enriched, and in some instances challenged, by deep-seated and widespread Burmese, Karen and Thai cultural norms known as Arr-nar (in Burmese and Karen) or Kreng-jai (in Thai), encompassing multiple meanings including consideration for others and graciousness. We offer a model illustrating how one might map ethically significant sociocultural influences across the research practice pathway and close with lessons for developing a more culturally responsive research ethics practice in other international settings.

Good participatory practice for coronavirus disease 2019 (COVID-19) research: the case of a COVID-19 prevention study

Background: The COPCOV study (chloroquine/ hydroxychloroquine prevention of coronavirus disease), which started recruitment in April 2020, is a multi-country double-blind, randomised, placebo-controlled trial which is being conducted in healthcare facilities involved in COVID-19 case management. Participants are staff employed in facilities managing people with proven or suspected COVID-19. As part of the study, we conducted a series of engagement sessions. The aims were to assess the feasibility of the study, to identify context-specific ethical issues, to understand possible concerns, to fine tune research procedures and to refine the COPCOV information materials. Methods: The COPCOV study was approved by relevant institutional review boards. The sessions described in this paper were part of the study. We conducted a series of engagement sessions, each involving a short presentation of the study, a section where attendees were asked to express their willingness to participate in such a study, which information they would need to change their view and an open Q&A section. Answers were transcribed and coded into themes by two independent investigators. Themes were derived from the data. They complemented other site-specific engagement, communication, and public relation activities such as press releases and websites. Results and conclusions: From 16 ^th March 2020 to 20 ^th January 2021, 12 engagement sessions were conducted in Thailand, Laos, Vietnam, Nepal and the UK involving 213 attendees in total. Issues raised revolved around the social value and study rationale; safety of trial medications and risk-benefit balance; study design and commitments. These sessions helped us identify  concerns people had, which helped us refine information materials as well as complement site feasibility assessments. Our experience strongly supports the use of participatory practices prior to conducting clinical trials.

Good participatory practice for coronavirus disease 2019 (COVID-19) research: the case of a COVID-19 prevention study

Background: The COPCOV study (chloroquine/ hydroxychloroquine prevention of coronavirus disease), which started recruitment in April 2020, is a multi-country double-blind, randomised, placebo-controlled trial which is being conducted in healthcare facilities involved in COVID-19 case management. COPCOV aims to recruit healthcare workers and other staff employed in facilities managing people with proven or suspected COVID-19. Methods: We conducted a series of engagement sessions, each involving a short presentation of the study, a section where attendees were asked to express if they would be interested in participating in such a study and which information they would need to change their view and an open Q&A section. Answers were transcribed and coded into themes by two independent investigators. Themes were derived from the data. The aims were to assess the feasibility of the study at the respective sites, to identify context-specific ethical issues, to understand concerns potential participants might have, to fine tune research procedures and to refine COPCOV information materials. They complemented other site-specific engagement, communication and public relation activities such as press releases and websites. Results: From 16 ^th March 2020 to 20 ^th January 2021, 12 engagement sessions were conducted in Thailand, Laos, Vietnam, Nepal and the UK involving 213 attendees in total. The sessions were designed to encourage potential participants and research professionals not directly involved in the project to interact with those who planned the study and those conducting it. Many attendees were keen to join the study while others had concerns. Questions raised revolved around the social value and study rationale; safety of trial medications and risk-benefit balance; study design and commitments. Conclusions: These sessions helped us refine information materials, identify misunderstandings about the study as well as complement site feasibility assessments. Our experience strongly supports the use of participatory practices prior to conducting clinical trials.

Challenges and Lessons Learned in the Development of a Participatory Learning and Action Intervention to Tackle Antibiotic Resistance: Experiences From Northern Vietnam

Antibiotic use in the community for humans and animals is high in Vietnam, driven by easy access to over-the counter medicines and poor understanding of the role of antibiotics. This has contributed to antibiotic resistance levels that are amongst the highest in the world. To address this problem, we developed a participatory learning and action (PLA) intervention. Here we describe challenges and lessons learned while developing and testing this intervention in preparation for a large-scale One Health trial in northern Vietnam. We tested the PLA approach using community-led photography, and then reflected on how this approach worked in practice. We reviewed and discussed implementation documentation and developed and refined themes. Five main themes were identified related to challenges and lessons learned: understanding the local context, stakeholder relationship development, participant recruitment, building trust and motivation, and engagement with the topic of antibiotics and antimicrobial resistance (AMR). Partnerships with national and local authorities provided an important foundation for building relationships with communities, and enhanced visibility and credibility of activities. Partnership development required managing relationships, clarifying roles, and accommodating different management styles. When recruiting participants, we had to balance preferences for top-down and bottom-up approaches. Building trust and motivation took time and was challenged by limited study team presence in the community. Open discussions around expectations and appropriate incentives were re-visited throughout the process. Financial incentives provided initial motivation to participate, while less tangible benefits like collective knowledge, social connections, desire to help the community, and new skills, sustained longer-term motivation. Lack of awareness and perceived importance of the problem of AMR, affected initial motivation. Developing mutual understanding through use of common and simplified language helped when discussing the complexities of this topic. A sense of ownership emerged as the study progressed and participants understood more about AMR, how it related to their own concerns, and incorporated their own ideas into activities. PLA can be a powerful way of stimulating community action and bringing people together to tackle a common problem. Understanding the nuances of local power structures, and allowing time for stakeholder relationship development and consensus-building are important considerations when designing engagement projects.

Steps Toward Engagement Integrity: Learning From Participatory Visual Methods in Marginalized South African Communities

Community engagement and involvement have been increasingly recognized as an ethical and valuable component of health science research over the past two decades. Progress has been accompanied by emerging standards that emphasize participation, two-way communication, inclusion, empowerment, and ownership. Although these are important and noble benchmarks, they can represent a challenge for research conducted in marginalized contexts. This community case study reports on the methods, outcomes, constraints and learning from an NGO-led community engagement project called Bucket Loads of Health, implemented in the Western Cape province of South Africa. The independent project team used multiple participatory visual methods to foster two-way communication between members of two disenfranchised communities, Enkanini and Delft, and a group of water microbiologists at Stellenbosch University who were conducting research in Enkanini. The project was carried out during the 2018 Western Cape water crisis, under the growing threat of “Day Zero”. The resulting visual outputs illustrated the negative impacts of water shortage on health and wellbeing in these community settings and showcased scientific endeavors seeking to address them. Engagement included knowledge exchange combining body maps, role play performances and films created by the community members, with hand maps, posters and presentations produced by the scientists. Whereas these engagement tools enabled reciprocal listening between all groups, their ability to respond to the issues raised was hindered by constraints in resources and capacity beyond their control. An additional core objective of the project was to bring the impacts of water shortage in participating communities, and the work of the research team, to the attention of local government. The case study demonstrates the challenges that politically ambitious community engagement faces in being acknowledged by government representatives. We further the argument that research institutions and funders need to match professed commitments to engagement with training and resources to support researchers and community members in responding to the needs and aspirations surfaced through engagement processes. We introduce the concept of engagement integrity to capture the gap between recommended standards of community engagement and what is realistically achievable in projects that are constrained by funding, time, and political interest.

Exploring the key anthropological drivers of and barriers to zoonotic malaria preventative behaviour in a community exposed to Plasmodium knowlesi infection in Malaysia: protocol for a qualitative study with a participatory research design

INTRODUCTION

Plasmodium knowlesi malaria is a zoonotic mosquito-borne disease with complex epidemiology. According to the WHO, the prevention and control of vector-borne diseases require community participation to increase coherence between malaria interventions and sustainable public health programmes. We describe a participatory research (PR) design for a study aimed at exploring the key anthropological drivers of and barriers to zoonotic malaria preventive behaviour among communities exposed to P. knowlesi infection in Malaysia. Participatory approaches can facilitate policymakers in designing future zoonotic malaria control programmes by investigating community perspectives and concerns about zoonotic malaria in a local context.

METHODS AND ANALYSIS

The PR will be conducted over a period of 12 months, from March 2022 to March 2023, among adults (>18 years old) who are permanent residents in a rural village exposed to P. knowlesi malaria in Sabah, Malaysia. We will select patients who were diagnosed with P. knowlesi infection from January to December 2021 for focus group discussions (FGDs), as they can provide perspectives on the disease from the point of view of those previously diagnosed with infection. In-depth interviews (IDIs) with people of importance in the community, such as village heads, will also be conducted. Both FGDs and IDIs will be conducted from March 2022 until June 2022. Concurrently, a photovoice with adults over 18 years old who reside in the community will be conducted. The target sample sizes for FGDs, IDIs and photovoice are 6-8, 12 and 10-15 participants, respectively. We will use a study framework as a theoretical lens to guide the exploration of the beliefs, social contexts, barriers and drivers surrounding zoonotic malaria preventive behaviour.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Research and Ethics Committee Ministry of Health Malaysia (NMRR ID-21-01980-JEH) and the Research and Innovation Secretariat, Faculty of Medicine, Universiti Kebangsaan Malaysia (FF-2021-462). All participants will provide consent prior to participation. The results will be reported in international peer-reviewed journals and presented at conferences and on other platforms.

Under the Mask: A Film on Tuberculosis at the Thai-Myanmar Border

In this paper, we describe the development of the film, “Under the Mask,” which follows the lives of three fictional characters who live on the Thai-Myanmar border as they journey from diagnosis of tuberculosis (TB) to completion of treatment. Under the Mask was filmed on location on the Thai-Myanmar border by local filmmakers and former refugee populations. Cast members were chosen from communities living along the border. This paper describes the script development process, filming, and screening in the community. We also report the findings from the pre- and post-screening questionnaires and post-film focus group discussions. A total of 77 screening events took place between March 2019 and March 2020 to 9,510 audience members in community venues such as village squares, temples and monasteries (N = 21), schools/migrant learning centers (N = 49), and clinics (N = 4). The pre-and post-screen questionnaires showed a significant gain in self-perceived TB knowledge on prevention, transmission, signs and symptoms, and related discrimination. Our findings from 18 post-screening focus group discussions conducted with 188 participants showed that there were improvements in knowledge and awareness of the disease and treatment, as well as in the awareness of stigma, and the burdens of tuberculosis on patients and their families.

Evaluating and Engaging: Using Participatory Video With Kenyan Secondary School Students to Explore Engagement With Health Research

Background

The growing ethical requirement to engage communities with health research has yielded diversification in approaches and targeted audiences. Conventional approaches like community “town-hall meetings,” laboratory open-days and focus group discussions, have evolved into new methods and audiences such as community drama and school engagement with health research (SEHR) involving learning interactions between researchers and school students. While engagement practices are diversifying, evaluations of these initiatives are rare in Low- and Middle-Income Countries (LMIC). This article focuses on the use of Participatory Video (PV) to explore the influence of the KEMRI-Wellcome Trust Research Programme's (KWTRP) School Engagement Programme (SEP) on the views and understandings of science and research among Kenyan state secondary school students.

Methods

Twelve male and twelve female students from four coeducational schools were provided with film-making kits (1 per school), and a one-day PV training workshop. They prepared 22 short films over 8 weeks depicting their experiences and views of research and engagement and conveying their career aspirations. Schools were selected based on prior SEP participation; two schools having experienced different engagement approaches, and the others with no prior school engagement. Study data comprised footage and participant observation notes.

Results

PV provided an opportunity to simultaneously engage and evaluate to inform practice. Through student-led filmmaking, PV stimulated conversations with students about research and engagement, enabling them to share their views in a way they felt was appropriate. These interactions offered an understanding of student gains from engagement, the depth of interaction required to address perceptions held about research and the potential unintended consequences of engagement. PV also provided insights into the context and complexity of life in which engagement is situated. Understanding this context is important because of its potential influence on participation in engagement activities. We draw on these insights to make two recommendations for school engagement practice. First is that PV can provide an enjoyable and insightful means of combining engagement with evaluation. Second, given that time for SEHR is competed for against other important curricular and extracurricular activities, SEHR practitioners must ensure that activities are as beneficial and enjoyable as possible to students.

What Does “Good” Community and Public Engagement Look Like? Developing Relationships With Community Members in Global Health Research

Community and public engagement (CPE) is increasingly becoming a key component in global health research. The National Institute for Health Research (NIHR) is one of the leading funders in the UK of global health research and requires a robust CPE element in the research it funds, along with CPE monitoring and evaluation. But what does “good” CPE look like? And what factors facilitate or inhibit good CPE? Addressing these questions would help ensure clarity of expectations of award holders, and inform effective monitoring frameworks and the development of guidance. The work reported upon here builds on existing guidance and is a first step in trying to identify the key components of what “good” CPE looks like, which can be used for all approaches to global health research and in a range of different settings and contexts. This article draws on data collected as part of an evaluation of CPE by 53 NIHR-funded award holders to provide insights on CPE practice in global health research. This data was then debated, developed and refined by a group of researchers, CPE specialists and public contributors to explore what “good” CPE looks like, and the barriers and facilitators to good CPE. A key finding was the importance, for some research, of investing in and developing long term relationships with communities, perhaps beyond the life cycle of a project; this was regarded as crucial to the development of trust, addressing power differentials and ensuring the legacy of the research was of benefit to the community.

"Theyabduct usand rapeus": Adolescents' participatory visual reflections of their vulnerability to sexual violence in South African townships

The abduction and sexual violation of adolescents, especially in township contexts, has increasingly made headlines in South Africa. These incidents are evocative of jackrolling, a phenomenon that plagued townships during the apartheid upheavals in the late 1980s. The abduction of adolescents on their school journeys has been reported in several South African townships. In this paper, we report on a study in which we used participatory visual methods (i.e., cellphilms: short videos made with cellphones) to explore how 19 adolescent girls and boys living in the Inanda, Ntuzuma, and KwaMashu (INK) township precinct, outside Durban reflected on their vulnerability to sexual violence. Although the question was broad, our analysis of the visual data suggests that adolescents believed that their vulnerability to abduction and rape was almost inevitable. As such, in their cellphilms, they chose to portray their risk and vulnerability to abduction, rape, and even murder on their daily journeys to and from school. We found that through this methodology, adolescents were able to illustrate and/or articulate their fear of sexual violence. For them, violence was an inescapable reality that created fear and helplessness. This underscores the need for interventions, including the provision of safe scholar transport and visible policing in the community.

Participatory approaches, local stakeholders and cultural relevance facilitate an impactful community-based project in Uganda

Sanitation is a major global challenge that is often addressed at national and international levels, while community opinions and beliefs are neglected. To promote water, sanitation and hygiene (WASH) we organized a cross-cultural knowledge exchange workshop to assess participatory methods for engaging local stakeholders. The workshop included 22 participants from all sectors of society. Practical solutions to sanitation challenges were identified and later shared with a local community. Qualitative and quantitative analyses were used to assess impact and showed participatory methods were highly valued to encourage information sharing among widely varied stakeholders, and that video was a particularly successful approach when engaging with local communities. An 8-month follow-up survey of village members revealed excellent information recall, positive behaviour changes and a desire for future visits. Our evidence suggests that community-based participation helped identify solutions to WASH issues affecting rural communities in resource-poor settings. Engaging in a multicultural knowledge-share was particularly valuable as it enabled participants to recognize they have common challenges and allowed them to share low-cost solutions from their different communities. Our use of video was widely viewed as an ideal means of circulating findings, as it communicated information to people with a wide variety of community roles and to all age groups. Its relevance was increased by adopting a culturally appropriate context by involving local communities in workshop activities. We recommend that research in low- and middle-income countries should be mindful of the environmental context in which WASH is implemented, and encourage acceptance by engaging with communities through the use of varied participatory methods.

Using the Emanuel Framework to Explore the Ethical Issues Raised in a Participatory Visual Research Project in Rural South Africa

Participatory visual research can offer critical insight into the experiences of those most affected by health issues. As these methods are increasingly used to research sensitive topics, there is a need for a clear ethical framework to guide best practice on the part of researchers and research ethics committees. Here we reflect on a project where we used digital storytelling as a participatory visual methodology to explore HIV treatment adherence in rural South Africa, with a focus on the ethical issues we encountered during the lifetime of the project. To ground our reflections, we use the framework for ethical research developed by Emanuel et al., and the adaptation of this framework for social science proposed by Wassenaar and Mamotte. We suggest that fellow PVM practitioners and REC members draw on this holistic framework to support the optimal application of PVM in health research.

Interest in Communication Technology by Rural Caregivers of Adolescents with Mental Health Issues in South Africa: The Mmogo-Method®

Caregivers determine the level of care adolescents with mental issues receive; however, caregivers' own needs are often unmet. Communication technology can be tailored to address these challenges, especially in a rural environment. This study aimed to explore caregivers' interest in using communication technology to provide support to address challenges. This study involved a visual-based narrative inquiry that gathered data through the Mmogo-method^®. Three (n = 3) groups were held with rural caregivers (n = 17) of adolescents with mental health issues in a rural area in the Free State province of South Africa during 2017. Three themes captured challenges confronting caregivers, namely, psychosocial, social resources, and informational challenges. Interest in communication technology was captured in a fourth theme. The findings indicate that communication technology can address caregivers' challenges by providing support and information to caregivers in rural areas. Communication technology, including mobile phones, electronic devices, and the Internet, has transformed healthcare services and proved to be valuable in resource constraint environments.

Research ethics in context: understanding the vulnerabilities, agency and resourcefulness of research participants living along the Thai-Myanmar border

BACKGROUND

Research ethics guidelines set a high bar for conducting research with vulnerable populations, often resulting in their exclusion from beneficial research. Our study aims to better characterise participants' vulnerabilities, agency, resourcefulness and sources of support.

METHODS

We undertook qualitative research around two clinical studies involving migrant women living along the Thai-Myanmar border. We conducted 32 in-depth interviews and 10 focus group discussions with research participants, families, researchers and key informants.

RESULTS

We found that being 'undocumented' is at the core of many structural vulnerabilities, reflecting political, economic, social and health needs. Although migrant women lead challenging lives, they have a support network that includes family, employers, community leaders, non-governmental organisations and research networks. Migrant women choose to participate in research to access quality healthcare, gain knowledge and obtain extra money. However, research has the potential to exacerbate existing vulnerabilities, such as the burdens of cross-border travel, foregoing work and being more visible as migrants.

CONCLUSIONS

Our study confirms that research is important to provide evidence-based care and was viewed by participants as offering many benefits, but it also has hidden burdens. Migrant women exercised agency and resourcefulness when navigating challenges in their lives and research participation.

A systematic literature review of the ethics of conducting research in the humanitarian setting

Background

Research around humanitarian crises, aid delivery, and the impact of these crises on health and well-being has expanded dramatically. Ethical issues around these topics have recently received more attention. We conducted a systematic literature review to synthesize the lessons learned regarding the ethics of research in humanitarian crises.

Methods

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify articles regarding the ethics of research in humanitarian contexts between January 1, 1997 and September 1, 2019. We analyzed the articles to extract key themes and develop an agenda for future research.

Results

We identified 52 articles that matched our inclusion criteria. We categorized the article data into five categories of analysis: 32 were expert statements, 18 were case studies, 11 contained original research, eight were literature reviews and three were book chapters. All included articles were published in English. Using a step-wise qualitative analysis, we identified 10 major themes that encompassed these concepts and points. These major themes were: ethics review process (21 articles, [40.38%]); community engagement (15 articles [28.85%]); the dual imperative, or necessity that research be both academically sound and policy driven, clinical trials in the humanitarian setting (13 articles for each, [25.0%)]; informed consent (10 articles [19.23%]); cultural considerations (6 articles, [11.54%]); risks to researchers (5 articles, [9.62%]); child participation (4 articles [7.69%]); and finally mental health, and data ownership (2 articles for each [3.85%]).

Conclusions

Interest in the ethics of studying humanitarian crises has been dramatically increasing in recent years. While key concepts within all research settings such as beneficence, justice and respect for persons are crucially relevant, there are considerations unique to the humanitarian context. The particular vulnerabilities of conflict-affected populations, the contextual challenges of working in humanitarian settings, and the need for ensuring strong community engagement at all levels make this area of research particularly challenging. Humanitarian crises are prevalent throughout the globe, and studying them with the utmost ethical forethought is critical to maintaining sound research principles and ethical standards.

Community engagement and ethical global health research

Community engagement is increasingly recognized as a critical element of medical research, recommended by ethicists, required by research funders and advocated in ethics guidelines. The benefits of community engagement are often stressed in instrumental terms, particularly with regard to promoting recruitment and retention in studies. Less emphasis has been placed on the value of community engagement with regard to ethical good practice, with goals often implied rather than clearly articulated. This article outlines explicitly how community engagement can contribute to ethical global health research by complementing existing established requirements such as informed consent and independent ethics review. The overarching and interlinked areas are (1) respecting individuals, communities and stakeholders; (2) building trust and social relationships; (3) determining appropriate benefits; minimizing risks, burdens and exploitation; (4) supporting the consent process; (5) understanding vulnerabilities and researcher obligations; (6) gaining permissions, approvals and building legitimacy and (7) achieving recruitment and retention targets.

Using Technology to Engage the Public in Biomedical Sciences

Biomedical research is a diverse and rapidly evolving subject area. The research and development that takes place as part of the field is aimed at understanding subjects such as diseases, disease progression, their treatment(s), treatment impact on patients as well as the general increase in understanding of the advancement of health sciences. The money and time invested in research is vast and discovery of novel data and production of publication(s) is seen as success. However in today's connected world scientists have to do more to ensure that their research and the impact thereof, is better communicated to the wider audiences. One of the major means to do this is via public engagement, of which there are many ways to achieve this. Advances in technology have led to interactive and immersive visual technologies that enable the next phase of public engagement to be available to a greater audience.

The use of participatory visual methods with community health workers: A systematic scoping review of the literature

With the need to design and evaluate Community Health Worker (CHW) programmes from a more human-centred perspective, researchers and programme managers are exploring the role of participatory visual methodologies (PVMs). This review identifies, maps, and assesses the quality of current literature that describes the use of PVMs with CHWs. It includes material from the grey literature and 10 major databases between 1978-2018. A Critical Appraisal Skills Programme (CASP) Qualitative checklist was used to assess the overall quality of the included studies. 12 original studies met the inclusion criteria. The studies were located in North America (n = 9) or sub-Saharan Africa (n = 3), with photovoice (n = 6) and digital storytelling (n = 5) being the most commonly used forms of PVMs. The overall quality of the evidence described in these articles was high, but it was notable that seven studies did not fully report the ethical considerations of their work. The studies revealed that PVMs can help assist CHWs' reflective practice and understanding of complex health issues, as well as identifying key issues in the community to potentially leverage social action.

Drama as a community engagement strategy for malaria in rural Cambodia

Background: Countries in Southeast Asia are working to eliminate multidrug-resistant falciparum malaria, a major cause of mortality in tropical regions. Malaria is declining but transmission persists in many rural areas and among forest workers and isolated populations. In these remote communities, conventional health services and education are limited. Mobilising and educating these populations require new approaches as many people are illiterate and do not attend village meetings. This article describes a qualitative study to assess the feasibility of a drama project as a community engagement strategy. Methods: A drama project was conducted in twenty villages in Cambodia with three key messages: to use insecticide-treated bednets and repellents, to get early diagnosis and treatment, and to learn about risks of forest-acquired malaria. Qualitative interviews were conducted with the drama team members, village malaria workers, local health staffs and villagers, to explore the feasibility of using drama to engage the community and the associated challenges. Results: 29 people were interviewed, which included 18 semi-structured interviews and one focus group discussion. Analysis of the interviews resulted in development of the following seven themes: i) exposure to malaria and engagement activities, ii) readiness and barriers to participation, iii) understanding and learning about malaria using drama, iv) entertainment value and engagement method preferences, v) challenges to community engagement, vi) future participation and vii) sustainability. The event saw a very positive response, with an encouraging average participation rate of 66%. The project faced several challenges including logistic problems, rescheduling due to raining season, and time- and budget-constraints. Conclusions: Our evaluation demonstrated that the drama project was feasible in promoting awareness and understanding of malaria prevention and control. Audience members perceived drama as entertaining and as the preferred choice of engagement activity. Participatory drama could be considered as part of the community engagement for malaria elimination.

Drama as a community engagement strategy for malaria in rural Cambodia

Background: Countries in Southeast Asia are working to eliminate multidrug-resistant falciparum malaria, a major cause of mortality in tropical regions. Malaria is declining but transmission persists in many rural areas and among forest workers and isolated populations. In these remote communities, conventional health services and education are limited. Mobilising and educating these populations require new approaches as many people are illiterate and do not attend village meetings. This article describes a qualitative study to assess the feasibility of a drama project as a community engagement strategy.

Methods: A drama project was conducted in twenty villages in Cambodia with three key messages: to use insecticide-treated bednets and repellents, to get early diagnosis and treatment, and to learn about risks of forest-acquired malaria. Qualitative interviews were conducted with the drama team members, village malaria workers, local health staffs and villagers, to explore the feasibility of using drama to engage the community and the associated challenges.

Results: 29 people were interviewed, which included 18 semi-structured interviews and one focus group discussion. Analysis of the interviews resulted in development of the following seven themes: i) exposure to malaria and engagement activities, ii) readiness and barriers to participation, iii) understanding and learning about malaria using drama, iv) entertainment value and engagement method preferences, v) challenges to community engagement, vi) future participation and vii) sustainability. The event saw a very positive response, with an encouraging average participation rate of 66%. The project faced several challenges including logistic problems, rescheduling due to raining season, and time- and budget-constraints.

Conclusions: Our evaluation demonstrated that the drama project was feasible in promoting awareness and understanding of malaria prevention and control. Audience members perceived drama as entertaining and as the preferred choice of engagement activity. Participatory drama could be considered as part of the community engagement for malaria elimination.