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Legendre E, Ndiaye A, Sougou NM, Gaudart J, Ba EH, Ridde V, Landier J. Prospective acceptability of mass drug administration for malaria in Kedougou region in Senegal: a mixed method study. Malar J 2024; 23:279. [PMID: 39285425 PMCID: PMC11406725 DOI: 10.1186/s12936-024-05078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/13/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND In Senegalese high-burden regions, the existing package of interventions is insufficient to reach the malaria elimination goal. Asymptomatic carriers of Plasmodium contribute significantly to malaria persistence and are not targeted by current interventions. The systematic treatment of all individuals in a community (mass drug administration, MDA) is a relevant intervention to tackle asymptomatic infections. The intervention can only be effective with a high participation of the population and, therefore, depends largely on its acceptability. This study aims to investigate the prospective acceptability of MDA in the Kedougou region to inform its potential use in a future strategy. METHODS Following a 7-construct theoretical framework, prospective acceptability of MDA implemented in the rainy season was studied. In four villages, a sequential mixed design, from qualitative to quantitative, was used. In November 2021, interviews with healthcare professionals and focus groups with villagers were conducted. Findings from thematic analysis informed the development of a questionnaire administered to individuals aged ≥ 15 years in March 2022. Based on the questionnaire, an acceptability score was constructed and associations with socio-demographic factors were investigated using a linear mixed model. RESULTS The 7 interviews, the 12 focus groups, and the questionnaire administered to 289 individuals demonstrated a good acceptability of MDA. Two potential barriers were identified: the contradiction of taking a medication without feeling sick and the occurrence of side effects; and four facilitators: the perception of malaria as a burden, a good understanding of MDA, a good perceived effectiveness, and the resulting economic benefits. The average acceptability score was 3.5 (range from -7 to + 7). Young adults aged 15 to 21 had a lower acceptability score compared to the other age groups, indicating an additional barrier to acceptability (β = -0.78 [-1.67;0.1]). CONCLUSION MDA is a priori acceptable to communities of Kedougou region in Senegal. Sensitization campaigns co-constructed with the communities, especially targeting young adults, are essential to ensure good acceptability.
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Affiliation(s)
- Eva Legendre
- Aix Marseille Univ, IRD, INSERM, SESSTIM, ISSPAM, Marseille, France.
| | - Antoine Ndiaye
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Ndèye Mareme Sougou
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Jean Gaudart
- Aix Marseille Univ, IRD, INSERM, SESSTIM, ISSPAM, AP-HM, La Timone Hospital, BioSTIC, Biostatistics and ICT, Marseille, France
| | - El Hadj Ba
- Institut de Recherche pour le Développement (IRD), Dakar, Sénégal
| | - Valéry Ridde
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD) et Université Paris Cité, Inserm ERL 1244, Paris, France
| | - Jordi Landier
- Aix Marseille Univ, IRD, INSERM, SESSTIM, ISSPAM, Marseille, France
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Aberese-Ako M, Doegah PT, Kpodo L, Ebelin W, Kuatewo M, Baba AA, Kpordorlor AG, Lissah SY, Kuug AK, Ansah E. The role of community engagement toward ensuring healthy lives: a case study of COVID-19 management in two Ghanaian municipalities. Front Public Health 2024; 11:1213121. [PMID: 38303963 PMCID: PMC10832024 DOI: 10.3389/fpubh.2023.1213121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/22/2023] [Indexed: 02/03/2024] Open
Abstract
Introduction Community engagement is one of the important requirements for strengthening health delivery in communities in a bid to achieve sustainable development goal 3, target 3.3 (SDG 3.3). The World Health Organization has strongly encouraged the use the five levels of community engagement, which are informing, consulting, planning, collaborating, and empowering communities in order to build resilience and to enable them contribute to the fight against diseases and for the uptake of health interventions. This study sought to explore and describe from the view of government institutions in Ghana how they engaged communities in COVID- 19 management and vaccine acceptance and how the communities within two municipalities also perceived the engagement process as well as the lessons that can be learned in engaging communities to deal with other health challenges and interventions toward the attainment of SDG 3 target 3.3. Materials and methods This case study qualitative research project employed in-depth interviews among 36 respondents composed of government officials (the Ghana Health Service (GHS), the Information Services Department (ISD), the National Commission on Civic Education (NCCE) and two Municipal Assemblies), and community leaders and 10 focus group discussions among 87 men and women most of whom were natives and some migrants in two administrative municipalities in Ghana. Data were collected from June to September 2021. Audio interviews were transcribed and uploaded to Nvivo 12 to support triangulation, coding, and thematic analysis. Ethical approval was obtained from the University of Health and Allied Sciences' Research Ethics Committee and all COVID-19 restrictions were observed. Results The findings revealed that all the four government institutions educated and informed the communities within their municipalities on COVID-19 management and vaccine acceptance. However, the Ghana Health Service was the most effective in the engagement spectrum of the other four; consulting, involving, collaborating, and empowering communities in the process of COVID-19 management and vaccine acceptance. The GHS achieved that through its CHPS program, which ensured a decentralized health service provision system with multiple programs and leveraging on its multiple programs to reach out to the communities. Government institutions such as the NCCE and the ISD faced challenges such as limited funding and support from the government to be able to carry out their tasks. Additionally, they were not involved with the communities prior to the pandemic and for that matter, they did not have access to community systems such as committees, and existing groups to facilitate the engagement process. Discussion Using communities to support Ghana's attainment of the SDG 3 target 3.3 is possible; however, the government needs to provide funds and resources to the institutions responsible to enable them to carry out community engagement effectively. Also, promoting decentralization among institutions can strengthen community engagement processes. It is important that state institutions continue to strategize to empower communities in order to promote their participation in healthcare interventions and in the fight against infectious diseases in Ghana.
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Affiliation(s)
- Matilda Aberese-Ako
- Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
| | | | | | - Wisdom Ebelin
- Evangelical Presbyterian Health Services, Evangelical Presbyterian Headquarters, Ho, Ghana
| | - Mawulom Kuatewo
- Hohoe Municipal Health Directorate, Ghana Health Service, Hohoe, Ghana
| | - Atubiga Alobit Baba
- School of Public Health, University of Health and Allied Sciences, Ho, Ghana
- Department of Hospitality and Tourism Management, Tamale Technical University, Tamale, Ghana
| | | | - Samuel Yaw Lissah
- Department of Agricultural Sciences and Technology, Faculty of Applied Sciences and Technology, Ho Technical University, Volta Region, Ghana
| | | | - Evelyn Ansah
- Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
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Oo MC, Phongluxa K, Oo WH, Kounnavong S, Xayyavong S, Louangphaxay C, Htike W, Cutts JC, Thu KM, Hkawng GN, Fowkes FJI. Perspectives of health and community stakeholders on community-delivered models of malaria elimination in Lao People’s Democratic Republic: A qualitative study. PLoS One 2022; 17:e0264399. [PMID: 35271594 PMCID: PMC8912149 DOI: 10.1371/journal.pone.0264399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/10/2022] [Indexed: 11/22/2022] Open
Abstract
In the Lao People’s Democratic Republic (Lao PDR), village health volunteers play an important role in providing health services including those to reduce the burden of malaria. Over the last two decades, the volunteer network has expanded to bring malaria services closer to communities and contributed to the reduction of malaria cases. However, as malaria test positivity rates decreased, many volunteers have lost motivation to continue providing routine malaria services, and other services they provide may not reflect growing healthcare demands for common diseases in the community. This study explored the perspectives, knowledge and inputs of key health stakeholders and community members in southern Lao PDR on community-delivered models in order to refine the volunteer model in the context of Lao PDR’s primary health care sector and malaria elimination goals. Semi-structured interviews with multi-level health stakeholders, participatory workshops with community leaders, and focus group discussions with community members and current village health volunteers were conducted. Deductive followed by inductive thematic analysis was used to explore and categorise stakeholders’ perspectives on community-delivered models for malaria elimination. Both stakeholders and community members agreed that village health volunteers are essential providers of malaria services in rural communities. Apart from malaria, community members identified dengue, diarrhoea, influenza, skin infections and tuberculosis as priorities (in descending order of importance) and requested community-based primary health care for these diseases. Stakeholders and community members suggested integrating prevention, diagnosis, and treatment services for the five priority diseases into the current malaria volunteer model. A divergence was identified between community members’ expectations of health services and the services currently provided by village health volunteers. Stakeholders proposed an integrated model of healthcare to meet the needs of the community and help to maintain volunteers’ motivation and the long-term sustainability of the role. An evidence-based, integrated community-delivered model of healthcare should be developed to balance the needs of both community members and stakeholders, with consideration of available resources and current health policies in Lao PDR.
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Affiliation(s)
- May Chan Oo
- Health Security Program, Burnet Institute Myanmar, Yangon, Myanmar
- * E-mail: (MCO); (WHO)
| | | | - Win Han Oo
- Health Security Program, Burnet Institute Myanmar, Yangon, Myanmar
- Disease Elimination Program, Burnet Institute, Victoria, Australia
- * E-mail: (MCO); (WHO)
| | | | - Syda Xayyavong
- Lao Tropical and Public Health Institute, Vientiane, Lao PDR
| | | | - Win Htike
- Health Security Program, Burnet Institute Myanmar, Yangon, Myanmar
| | - Julia C. Cutts
- Disease Elimination Program, Burnet Institute, Victoria, Australia
| | - Kaung Myat Thu
- Health Security Program, Burnet Institute Myanmar, Yangon, Myanmar
| | - Galau Naw Hkawng
- Health Security Program, Burnet Institute Myanmar, Yangon, Myanmar
| | - Freya J. I. Fowkes
- Disease Elimination Program, Burnet Institute, Victoria, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
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Kaehler N, Adhikari B, Cheah PY, von Seidlein L, Day NPJ, Dondorp AM, Pell C. Community engagement for malaria elimination in the Greater Mekong Sub-region: a qualitative study among malaria researchers and policymakers. Malar J 2022; 21:46. [PMID: 35164770 PMCID: PMC8845385 DOI: 10.1186/s12936-022-04069-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community engagement has increasingly received attention in malaria research and programme interventions, particularly as countries aim for malaria elimination. Although community engagement strategies and activities are constantly developing, little is known about how those who implement research or programmes view community engagement. This article explores the perspectives of researchers and policy makers in the Greater Mekong Sub-region (GMS) on community engagement for malaria control and elimination. METHODS Semi-structured interviews were conducted among 17 policymakers and 15 senior researchers working in the field of malaria. All interviews were audio-recorded and transcribed in English. Transcribed data were analysed using deductive and inductive approaches in QSR NVivo. Themes and sub-themes were generated. RESULTS Researchers and policymakers emphasized the importance of community engagement in promoting participation in malaria research and interventions. Building trust with the community was seen as crucial. Respondents emphasized involving authority/leadership structures and highlighted the need for intense and participatory engagement. Geographic remoteness, social, cultural, and linguistic diversity were identified as barriers to meaningful engagement. Local staff were described as an essential 'connect' between researchers or policymakers and prospective participants. Sharing information with community members, using various strategies including creative and participatory methods were highlighted. CONCLUSIONS Policymakers and researchers involved in malaria prevention and control in the GMS viewed community engagement as crucial for promoting participation in research or programmatic interventions. Given the difficulties of the 'last mile' to elimination, sustained investment in community engagement is needed in isolated areas of the GMS where malaria transmission continues. Involving community-based malaria workers is ever more critical to ensure the elimination efforts engage hard-to-reach populations in remote areas of GMS.
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Affiliation(s)
- Nils Kaehler
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
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Tilaye T, Tessema B, Alemu K. Malaria Infection is High at Transit and Destination Phases Among Seasonal Migrant Workers in Development Corridors of Northwest Ethiopia: A Repeated Cross-Sectional Study. Res Rep Trop Med 2021; 12:107-121. [PMID: 34079425 PMCID: PMC8165298 DOI: 10.2147/rrtm.s306001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/24/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose Malaria is a leading public health problem in Ethiopia. Every year, thousands of seasonal farm workers travel to farm corridors in Northwest Ethiopia and fall at risk of malaria infection. However, the magnitude of malaria infection and risk factors during harvest time were not well identified. This study aimed at estimating the prevalence and risk factors of malaria infection among seasonal migrant workers in Northwest Ethiopia. Methods A repeated cross-sectional study was conducted at transit and destination phases in Metema district from September 15, 2018 to October 30, 2019. Data were collected using a structured questionnaire. A capillary blood sample was collected to examine infection with malaria parasite using a microscope. A multivariate logistic regression technique was used to determine risk factors. Results The malaria prevalence at transit and destination phases among migrant workers was 13.5% (95% CI: 12.07–14.93%) and 18.7% (95% CI: 16.40–21.02%), respectively. The combined prevalence was 16.1% (95% CI: 14.67–17.63%). The odds of malaria infection among migrant workers at the destination phase was 1.5 (OR=1.5, 95% CI 1.167–1.846) times higher compared to the transit phase. Education (AOR=8.198; 95% CI: 4.318–15.564), knowledge of antimalarial drugs (AOR=2.4; 95% CI: 1.43–3.95), and use of long-lasting insecticidal nets (AOR=5.0; 95% CI: 3.34–4.43) were significantly associated with malaria infection at migration phases. Conclusion This study showed that the burden of malaria among seasonal migrant workers was high at transit and destination phases. Malaria prevalence was higher at the destination phase compared to the transit phase. A tailored malaria prevention intervention is needed including awareness creation, screening, treatment, repellent, and prophylaxis at both phases to reduce malaria infections.
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Affiliation(s)
- Tesfaye Tilaye
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Belay Tessema
- Department of Medical Microbiology, School of Biomedical and Medical Laboratory, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Cheng B, Htoo SN, Mhote NPP, Davison CM. A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia. Malar J 2021; 20:195. [PMID: 33879186 PMCID: PMC8056550 DOI: 10.1186/s12936-021-03733-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Multi-pronged malaria elimination strategies are increasingly being considered for accelerating efforts against malaria transmission in Southeast Asia. Two malaria prevention interventions used in in the region are insecticide-treated bed-nets (ITNs) and mass drug administration (MDA). Universal access to ITNs is recommended and high population coverage (e.g. above 80%) is needed during MDA initiatives to maximize the impact of these interventions. However, variability in ITN use and individual MDA participation exists. This systematic review aims to provide a summary and overview of literature discussing factors influencing uptake of these two malaria control strategies in Southeast Asian countries. Methods A search of OVID Embase, OVID MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, OpenGrey, ProQuest, and Google Scholar was undertaken in February 2020. English-language publications with any study design using data from any of the ten member countries of the Association of Southeast Asian Nations were eligible for inclusion. In addition, reference lists of identified articles were manually searched. Websites for relevant international agencies were also searched to identify related grey literature. Results The review identified thirty publications that met the inclusion and exclusion criteria. Most discussed ITN use (n = 18) and were relevant to populations in Myanmar (n = 14). All MDA studies were published after 2016, whereas included ITN studies spanned from 1998 to 2020. Seven main themes emerged across the studies. Knowledge of malaria and attitudes towards ITNs were emphasized as key factors associated with ITN use. For MDA participation, key factors included the importance of positive attitudes towards the program, the influence of indirect costs and incentives, and the tendency for group decision-making. Conclusions As countries in Southeast Asia continue to work towards becoming malaria-free by 2030, the knowledge and attitudes of local population sub-groups should be assessed and incorporated into the planning and implementation of malaria prevention activities. The role of incentives and group decision making should also be considered particularly as they relate to MDA. There is need for ongoing involvement of health educators, the continuation of implementation research and the prioritization of community engagement efforts alongside malaria interventions in the region. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03733-y.
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Affiliation(s)
- Breagh Cheng
- Department of Public Health Sciences, Queen's University, 62 Fifth Field Company Lane, Kingston, ON, K7L3N6, Canada
| | | | | | - Colleen M Davison
- Department of Public Health Sciences, Queen's University, 62 Fifth Field Company Lane, Kingston, ON, K7L3N6, Canada.
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Galatas B, Nhantumbo H, Soares R, Djive H, Murato I, Simone W, Macete E, Rabinovich NR, Alonso P, Candrinho B, Saúte F, Aide P, Munguambe K. Community acceptability to antimalarial mass drug administrations in Magude district, Southern Mozambique: A mixed methods study. PLoS One 2021; 16:e0249080. [PMID: 33755685 PMCID: PMC7987150 DOI: 10.1371/journal.pone.0249080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/10/2021] [Indexed: 11/19/2022] Open
Abstract
Background This study aimed to capture the acceptability prior to, during and after the implementation of the first year of MDA rounds conducted under the Magude project, a malaria elimination project in southern Mozambique. Methods This was a mixed-methods study, consisting of focus group discussions (FGDs) prior to the implementation of MDA rounds (September 2015), non-participant observations (NPOs) conducted during the MDA rounds (November 2015 –beginning of February 2016), and semi-structured interviews (SSIs) after the second round (end of February 2016). Community leaders, women in reproductive age, general members of the community, traditional healers and health professionals were recruited to capture the opinions of all representing key members of the community. A generic outline of nodes and codes was designed to analyze FGDs and SSI separately. Qualitative and quantitative NPO information was analyzed following a content analysis approach. Findings 222 participants took part in the FGDs (n = 154), and SSIs (n = 68); and 318 household visits during the MDA underwent NPOs. The community engagement campaign emerged throughout the study stages as a crucial factor for the acceptability of MDAs. Acceptability was also fostered by the community’s general will to cooperate in any government-led activity that would reduce malaria burden, the appropriate behavior and knowledge of field workers, or the fact that the intervention was available free of charge to all. Absenteeism of heads of households was identified as the main barrier for the success of the campaign. The most commonly reported factors that negatively affected acceptability were the fear of adverse events, rumors of deaths, being unable to drink alcohol while taking DHAp, or the fear to take DHAp while in anti-retroviral treatment. Pregnancy testing and malaria testing were generally well accepted by the community. Conclusion Magude’s community generally accepted the first and second antimalarial MDA rounds, and the procedures associated to the intervention. Future implementation of antimalarial MDAs in southern Mozambique should focus on locally adapted strategies that engage the community to minimize absenteeism and refusals to the intervention.
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Affiliation(s)
- Beatriz Galatas
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- * E-mail:
| | | | - Rodolfo Soares
- Center for International Studies (CEI-IUL), Lisbon, Portugal
| | - Helder Djive
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Ilda Murato
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Wilson Simone
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- National Directorate of Health, Ministry of Health, Maputo, Mozambique
| | - N. Regina Rabinovich
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Pedro Alonso
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Baltazar Candrinho
- National Malaria Control Programme (NMCP), Ministry of Health, Maputo, Mozambique
| | - Francisco Saúte
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- National Institute of Health, Ministry of Health, Maputo, Mozambique
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
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Silumbe K, Finn TP, Jennings T, Sikombe C, Chiyende E, Hamainza B, Chizema Kawesha E, Eisele TP, Earle D, Steketee RW, Miller JM. Assessment of the Acceptability of Testing and Treatment during a Mass Drug Administration Trial for Malaria in Zambia Using Mixed Methods. Am J Trop Med Hyg 2020; 103:28-36. [PMID: 32618242 PMCID: PMC7416978 DOI: 10.4269/ajtmh.19-0663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
From 2014 to 2016, a community-randomized controlled trial in Southern Province, Zambia, compared mass drug administration (MDA) and focal MDA (fMDA) with the standard of care. Acceptability of the intervention was assessed quantitatively using closed-ended and Likert scale-based questions posed during three household surveys conducted from April to May in 2014, 2015, and 2016 in 40 health catchments that implemented MDA and fMDA and 20 catchments that served as trial controls. In 2014 and 2015, 47 households per catchment were selected, targeting 1,880 households in MDA and fMDA trial arms; in 2016, 55 households per catchment were selected for a target of 2,200 households in MDA and fMDA trial arms. Concurrently, 27 focus group discussions and 23 in-depth interviews with 248 participants were conducted on reasons for testing and treatment refusal, reasons for nonadherence, and community perception of the MDA campaign. Results demonstrated that the MDA campaign was highly accepted with more than 99% of respondents stating that they would take treatment if positive for malaria. High acceptability at baseline could be associated with test-and-treat campaigns recently conducted in the study area. There was a large increase in the acceptability of prophylactic treatment if negative for malaria from the baseline to follow-up survey for adults and children, from 62% to 96% for each. This likely resulted from an intensive community-wide sensitization program that occurred before the first treatment round at each household during community health worker visits.
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Affiliation(s)
- Kafula Silumbe
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Timothy P Finn
- Department of Tropical Medicine, Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Todd Jennings
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Chilumba Sikombe
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Elizabeth Chiyende
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Busiku Hamainza
- National Malaria Elimination Centre, Zambia Ministry of Health, Lusaka, Zambia
| | | | - Thomas P Eisele
- Department of Tropical Medicine, Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Duncan Earle
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Richard W Steketee
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - John M Miller
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
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Phommasone K, van Leth F, Peto TJ, Landier J, Nguyen TN, Tripura R, Pongvongsa T, Lwin KM, Kajeechiwa L, Thwin MM, Parker DM, Wiladphaingern J, Nosten S, Proux S, Nguon C, Davoeung C, Rekol H, Adhikari B, Promnarate C, Chotivanich K, Hanboonkunupakarn B, Jittmala P, Cheah PY, Dhorda M, Imwong M, Mukaka M, Peerawaranun P, Pukrittayakamee S, Newton PN, Thwaites GE, Day NPJ, Mayxay M, Hien TT, Nosten FH, Cobelens F, Dondorp AM, White NJ, von Seidlein L. Mass drug administrations with dihydroartemisinin-piperaquine and single low dose primaquine to eliminate Plasmodium falciparum have only a transient impact on Plasmodium vivax: Findings from randomised controlled trials. PLoS One 2020; 15:e0228190. [PMID: 32023293 PMCID: PMC7001954 DOI: 10.1371/journal.pone.0228190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022] Open
Abstract
Background Mass administrations of antimalarial drugs (MDA) have reduced the incidence and prevalence of P. falciparum infections in a trial in the Greater Mekong Subregion. Here we assess the impact of the MDA on P. vivax infections. Methods Between May 2013 and July 2017, four villages in each Myanmar, Vietnam, Cambodia and Lao PDR were selected based on high prevalence of P. falciparum infections. Eight of the 16 villages were randomly assigned to receive MDA consisting of three-monthly rounds of three-day courses of dihydroartemisinin-piperaquine and, except in Cambodia, a single low-dose of primaquine. Cross-sectional surveys were conducted at quarterly intervals to detect Plasmodium infections using ultrasensitive qPCR. The difference in the cumulative incidence between the groups was assessed through a discrete time survival approach, the difference in prevalence through a difference-in-difference analysis, and the difference in the number of participants with a recurrence of P. vivax infection through a mixed-effect logistic regression. Results 3,790 (86%) residents in the intervention villages participated in at least one MDA round, of whom 2,520 (57%) participated in three rounds. The prevalence of P. vivax infections fell from 9.31% to 0.89% at month 3 but rebounded by six months to 5.81%. There was no evidence that the intervention reduced the cumulative incidence of P.vivax infections (95% confidence interval [CI] Odds ratio (OR): 0.29 to 1.36). Similarly, there was no evidence of MDA related reduction in the number of participants with at least one recurrent infection (OR: 0.34; 95% CI: 0.08 to 1.42). Conclusion MDA with schizontocidal drugs had a lasting effect on P. falciparum infections but only a transient effect on the prevalence of P. vivax infections. Radical cure with an 8-aminoquinoline will be needed for the rapid elimination of vivax malaria.
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Affiliation(s)
- Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- Department of Global Health, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
- Amsterdam Institute for Global Health & Development, Amsterdam, Netherlands
| | - Frank van Leth
- Department of Global Health, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
- Amsterdam Institute for Global Health & Development, Amsterdam, Netherlands
| | - Thomas J. Peto
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Jordi Landier
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Institut de Recherche pour le Développement (IRD), Institut national de la santé et de la recherche médical (INSERM), Aix-Marseille Université · SESSTIM, Marseille, France
| | - Thuy-Nhien Nguyen
- Oxford University Clinical Research Unit, Wellcome Trust Major Oversea Programme, Ho Chi Minh City, Vietnam
| | - Rupam Tripura
- Department of Global Health, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Savannakhet Province, Lao People’s Demographic Republic
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Ladda Kajeechiwa
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Daniel M. Parker
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Department of Population Health and Disease Prevention, University of California, Irvine, California, United States of America
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Suphak Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Chea Nguon
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | - Huy Rekol
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Bipin Adhikari
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Cholrawee Promnarate
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Worldwide Antimalarial Resistance Network (WWARN) Asia Regional Centre, Mahidol University, Bangkok, Thailand
| | - Kesinee Chotivanich
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Borimas Hanboonkunupakarn
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Podjanee Jittmala
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Worldwide Antimalarial Resistance Network (WWARN) Asia Regional Centre, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Pimnara Peerawaranun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sasithon Pukrittayakamee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- The Royal Society of Thailand, Dusit, Bangkok, Thailand
| | - Paul N. Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Guy E. Thwaites
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
- Oxford University Clinical Research Unit, Wellcome Trust Major Oversea Programme, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao People’s Demographic Republic
| | - Tran Tinh Hien
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
- Oxford University Clinical Research Unit, Wellcome Trust Major Oversea Programme, Ho Chi Minh City, Vietnam
| | - Francois H. Nosten
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Frank Cobelens
- Department of Global Health, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
- Amsterdam Institute for Global Health & Development, Amsterdam, Netherlands
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
| | - Lorenz von Seidlein
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, England, United Kingdom
- * E-mail:
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10
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Peto TJ, Tripura R, Sanann N, Adhikari B, Callery J, Droogleever M, Heng C, Cheah PY, Davoeung C, Nguon C, von Seidlein L, Dondorp AM, Pell C. The feasibility and acceptability of mass drug administration for malaria in Cambodia: a mixed-methods study. Trans R Soc Trop Med Hyg 2019; 112:264-271. [PMID: 29917147 PMCID: PMC6044409 DOI: 10.1093/trstmh/try053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/16/2018] [Indexed: 01/27/2023] Open
Abstract
Background Mass drug administrations (MDAs) are part of the World Health Organization’s Plasmodium falciparum elimination strategy for the Greater Mekong Subregion (GMS). In Cambodia, a 2015–2017 clinical trial evaluated the effectiveness of MDA. This article explores factors that influence the feasibility and acceptability of MDA, including seasonal timing, financial incentives and the delivery model. Methods Quantitative data were collected through structured questionnaires from the heads of 163 households. Qualitative data were collected through 25 semi-structured interviews and 5 focus group discussions with villagers and local health staff. Calendars of village activities were created and meteorological and malaria treatment records were collected. Results MDA delivered house-to-house or at a central point, with or without compensation, were equally acceptable and did not affect coverage. People who knew about the rationale for the MDA, asymptomatic infections and transmission were more likely to participate. In western Cambodia, MDA delivered house-to-house by volunteers at the end of the dry season may be most practicable but requires the subsequent treatment of in-migrants to prevent reintroduction of infections. Conclusions For MDA targeted at individual villages or village clusters it is important to understand local preferences for community mobilisation, delivery and timing, as several models of MDA are feasible.
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Affiliation(s)
- Thomas J Peto
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rupam Tripura
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Nou Sanann
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - James Callery
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mark Droogleever
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Chhouen Heng
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Chan Davoeung
- Battambang Provincial Health Department, Mohatep Street, Battambang, Cambodia
| | - Chea Nguon
- National Centre for Parasitology, Entomology and Malaria Control, 477 Betong, Khan Sen Sok, Phnom Penh, Cambodia
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
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11
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SHAHANDEH K, BASSERI HR. Challenges and the Path Forward on Malaria Elimination Intervention: A Systematic Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2019; 48:1004-1013. [PMID: 31341841 PMCID: PMC6635336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This systematic review was conducted to highlights key challenges, and outlines important next steps to maximize the potential to contribute to the broader malaria elimination interventions. METHODS This systematic review on malaria elimination intervention and challenges was undertaken searching six databases, between 1995 and 2018. Inclusion and exclusion criteria were set. The references were collated and categorized according to type of study, intervention, population, and health outcome. Articles selection based on title and abstract, retrieval of full text and additions of articles from reference lists and recommendations from experts. Disagreement in data extraction was solved by consultation of third reviewer. RESULTS Overall, 4039 records were examined related to malaria elimination that initially identified by our designated electronic databases search. Overall, 35 studies contained 14 experimental studies (40%) and 21 analytic observational studies (60%) met the inclusion criteria for this review. Studies used a wide variety of malaria elimination interventions. Types of interventions either elimination-focused interventions or general interventions on educational, prevention and treatment of malaria are included. This review pointed out the variety of challenges for eliminate malaria among low and high endemic countries. CONCLUSION Malaria elimination is facilitated by strong health systems, determined leadership, appropriate incentivization, an effective surveillance system, and regional collaborations. We have identified areas for elimination-specific interventions deserve more attention in the conduct and reporting.
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Affiliation(s)
- Khandan SHAHANDEH
- Deputy of Research and Technology, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza BASSERI
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Author:
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12
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Kaehler N, Adhikari B, Cheah PY, Day NPJ, Paris DH, Tanner M, Pell C. The promise, problems and pitfalls of mass drug administration for malaria elimination: a qualitative study with scientists and policymakers. Int Health 2019; 11:166-176. [PMID: 30395228 PMCID: PMC6484636 DOI: 10.1093/inthealth/ihy079] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/01/2018] [Accepted: 09/09/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The emergence of artemisinin resistance in the Greater Mekong Subregion (GMS) has prompted urgent containment measures. One possible approach is mass drug administration (MDA). This article explores attitudes towards and perceptions of MDA for malaria elimination among policymakers and leading malariologists. METHODS Thirty-two semistructured interviews (SSI) were conducted with policymakers (n=17) and principal investigators (n=15) selected based on their involvement in malaria prevention, control and elimination in the GMS. Interviews were audio recorded and transcribed for qualitative content (thematic) analysis using NVivo (QSR International, Doncaster, Victoria, Australia). RESULTS Researchers and policymakers described reluctance and consequently delays to pilot MDA for malaria elimination. Most policymakers and some researchers reported concerns around the evidence base, citing a lack of data on its effectiveness and appropriate target populations. There were also worries about promoting resistance. Other issues included a previous lack of support from the World Health Organization, past MDAs, the remoteness of target populations and challenges explaining the rationale for MDA. CONCLUSIONS The complex rationale for MDA for malaria elimination, mistaking pilot studies for implementation, past experiences with MDA, difficulties in selecting appropriate sites and the WHO's lack of clear backing undermined the support for MDA for malaria elimination.
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Affiliation(s)
- Nils Kaehler
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Bipin Adhikari
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, UK
| | - Nicholas P J Day
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam Health Technology Centre, Tower C4, Paasheuvelweg 25, BP Amsterdam, The Netherlands
- Centre for Social Science and Global Health, University of Amsterdam, Nieuwe Achtergracht 166, WV, Amsterdam, The Netherlands
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13
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Adhikari B, Phommasone K, Pongvongsa T, Koummarasy P, Soundala X, Henriques G, Sirithiranont P, Parker DM, von Seidlein L, White NJ, Day NPJ, Dondorp AM, Newton PN, Cheah PY, Pell C, Mayxay M. Treatment-seeking behaviour for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos): a mixed method study. BMC Health Serv Res 2019; 19:252. [PMID: 31018855 PMCID: PMC6480816 DOI: 10.1186/s12913-019-4070-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 04/08/2019] [Indexed: 02/06/2023] Open
Abstract
Background How people respond to febrile illness is critical to malaria prevention, control, and ultimately elimination. This article explores factors affecting treatment-seeking behaviour for febrile illnesses in a remote area of Lao PDR. Methods Household heads or their representatives (n = 281) were interviewed using a structured questionnaire. A total of twelve focus group discussions (FGDs) each with eight to ten participants were conducted in four villages. In addition, observations were recorded as field notes (n = 130) and were used to collect information on the local context, including the treatment seeking behaviour and the health services. Results Almost three-quarters (201/281) of respondents reported fever in past two months. Most (92%, 185/201) sought treatment of which 80% (149/185) sought treatment at a health centre. Geographic proximity to a health centre (AOR = 6.5; CI = 1.74–24.25; for those < 3.5 km versus those > 3.6 km) and previous experience of attending a health centre (AOR = 4.7; CI = 1.2–19.1) were strong predictors of visiting a health centre for febrile symptoms. During FGDs, respondents described seeking treatment from traditional healers and at health centre for mild to moderate illnesses. Respondents also explained how if symptoms, including fever, were severe or persisted after receiving treatment elsewhere, they sought assistance at health centres. Access to local health centres/hospitals was often constrained by a lack of transportation and an ability to meet the direct and indirect costs of a visit. Conclusion In Nong District, a rural area bordering Vietnam, people seek care from health centres offering allopathic medicine and from spiritual healers. Decisions about where and when to attend health care depended on their economic status, mobility (distance to the health centre, road conditions, availability of transport), symptoms severity and illness recognition. Current and future malaria control/elimination programmes could benefit from greater collaboration with the locally accessible sources of treatments, such as health volunteers and traditional healers.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Kellogg College, University of Oxford, Oxford, UK.
| | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Laos
| | | | - Palingnaphone Koummarasy
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Laos
| | - Xayaphone Soundala
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Laos
| | - Gisela Henriques
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Pasathorn Sirithiranont
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Daniel M Parker
- Department of Population Health and Disease Prevention, University of California, Irvine, California, USA
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Paul N Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Laos
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Laos.,Institute of Research and Educational Development, University of Health Sciences, Vientiane, Laos
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14
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Pell CL, Adhikari B, Myo Thwin M, Kajeechiwa L, Nosten S, Nosten FH, Sahan KM, Smithuis FM, Nguyen TN, Hien TT, Tripura R, Peto TJ, Sanann N, Nguon C, Pongvongsa T, Phommasone K, Mayxay M, Mukaka M, Peerawaranun P, Kaehler N, Cheah PY, Day NPJ, White NJ, Dondorp AM, von Seidlein L. Community engagement, social context and coverage of mass anti-malarial administration: Comparative findings from multi-site research in the Greater Mekong sub-Region. PLoS One 2019; 14:e0214280. [PMID: 30908523 PMCID: PMC6433231 DOI: 10.1371/journal.pone.0214280] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/11/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Between 2013 and 2017, targeted malaria elimination (TME), a package of interventions that includes mass drug administration (MDA)-was piloted in communities with reservoirs of asymptomatic P. falciparum across the Greater Mekong sub-Region (GMS). Coverage in target communities is a key determinant of the effectiveness of MDA. Drawing on mixed methods research conducted alongside TME pilot studies, this article examines the impact of the community engagement, local social context and study design on MDA coverage. METHODS AND FINDINGS Qualitative and quantitative data were collected using questionnaire-based surveys, semi-structured and in-depth interviews, focus group discussions, informal conversations, and observations of study activities. Over 1500 respondents were interviewed in Myanmar, Vietnam, Cambodia and Laos. Interview topics included attitudes to malaria and experiences of MDA. Overall coverage of mass anti-malarial administration was high, particularly participation in at least a single round (85%). Familiarity with and concern about malaria prompted participation in MDA; as did awareness of MDA and familiarity with the aim of eliminating malaria. Fear of adverse events and blood draws discouraged people. Hence, community engagement activities sought to address these concerns but their impact was mediated by the trust relationships that study staff could engender in communities. In contexts of weak healthcare infrastructure and (cash) poverty, communities valued the study's ancillary care and the financial compensation. However, coverage did not necessarily decrease in the absence of cash compensation. Community dynamics, affected by politics, village conformity, and household decision-making also affected coverage. CONCLUSIONS The experimental nature of TME presented particular challenges to achieving high coverage. Nonetheless, the findings reflect those from studies of MDA under implementation conditions and offer useful guidance for potential regional roll-out of MDA: it is key to understand target communities and provide appropriate information in tailored ways, using community engagement that engenders trust.
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Affiliation(s)
- Christopher L. Pell
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Bipin Adhikari
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Ladda Kajeechiwa
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Suphak Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Francois H. Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Sorbonne Universités, UPMC Univ Paris 06, UPMC UMRS CR7, Paris, France
| | - Kate M. Sahan
- Ethox Centre and Wellcome Centre for Ethics and Humanities, Nuffield Department of Population Health, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
| | - Frank M. Smithuis
- Medical Action Myanmar, Yangon, Myanmar
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Thuy-Nhien Nguyen
- Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, Ho Chi Minh City, Vietnam
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, Ho Chi Minh City, Vietnam
| | - Rupam Tripura
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas J. Peto
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nou Sanann
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chea Nguon
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Lao PDR
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Lao PDR
- Institute of Research and Educational Development, University of Health Sciences, Vientiane, Lao PDR
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Pimnara Peerawaranun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nils Kaehler
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Ethox Centre and Wellcome Centre for Ethics and Humanities, Nuffield Department of Population Health, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Lorenz von Seidlein
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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15
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Tangseefa D, Monthathip K, Tuenpakdee N, König A, Kajeechiwa L, Thwin MM, Nosten S, Tun SW, Ma K, Hashmi A, Lwin KM, Cheah PY, von Seidlein L, Nosten F. "Nine Dimensions": A multidisciplinary approach for community engagement in a complex postwar border region as part of the targeted malaria elimination in Karen/Kayin State, Myanmar. Wellcome Open Res 2019; 3:116. [PMID: 30687790 PMCID: PMC6343222 DOI: 10.12688/wellcomeopenres.14698.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 11/20/2022] Open
Abstract
Background: In light of growing antimalarial drug resistance in Southeast Asia, control programmes have become increasingly focused on malaria elimination, composed of mass drug administration coupled with prompt diagnosis and treatment of symptomatic cases. The key to a successful elimination programme centres on high participation rates in targeted communities, often enhanced by community engagement (CE) efforts. Social science research was conducted to develop a conceptual framework used for CE activities in the Targeted Malaria Elimination programme, as a cross-border operation in Karen/Kayin State, Myanmar. Methods: Data was collected from three main sources: (1) participant observation and semi-structured interviews of CE team members; (2) participant observation and semi-structured interviews with villagers; and (3) records of CE workshops with CE workers conducted as part of the TME programme. Results: Interviews were conducted with 17 CE team members, with 10 participant observations and interviews conducted with villagers and a total of 3 workshops conducted over the course of this pilot programme in 4 villages (November 2013 to October 2014). Thematic analysis was used to construct the nine dimensions for CE in this complex, post-war region: i) history of the people; ii) space; iii) work; iv) knowledge about the world; v) intriguing obstacle (rumour); vi) relationship with the health care system; vii) migration; viii) logic of capitalism influencing openness; and ix) power relations. Conclusions: Conducting CE for the Targeted Malaria Elimination programme was immensely complicated in Karen/Kayin State because of three key realities: heterogeneous terrains, a post-war atmosphere and cross-border operations. These three key realities constituted the nine dimensions, which proved integral to health worker success in conducting CE. Summary of this approach can aid in infectious disease control programmes, such as those using mass drug administration, to engender high rates of community participation.
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Affiliation(s)
- Decha Tangseefa
- Center for Southeast Asian Studies, Kyoto University, Kyoto, 606-8501, Japan.,Faculty of Political Science, Thammasat University, Bangkok, 10200, Thailand
| | - Krishna Monthathip
- Department of International Politics, Aberystwyth University, Aberystwyth, West Wales, SY23 3FL, UK
| | | | - Andrea König
- Peace Information Center, Faculty of Political Science, Thammasat University, Bangkok, 10200, Thailand
| | - Ladda Kajeechiwa
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Suphak Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Saw Win Tun
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Kayin Ma
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Ahmar Hashmi
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Phaik Yeong Cheah
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Lorenz von Seidlein
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
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16
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Tangseefa D, Monthathip K, Tuenpakdee N, König A, Kajeechiwa L, Thwin MM, Nosten S, Tun SW, Ma K, Hashmi A, Lwin KM, Cheah PY, von Seidlein L, Nosten F. "Nine Dimensions": A multidisciplinary approach for community engagement in a complex postwar border region as part of the targeted malaria elimination in Karen/Kayin State, Myanmar. Wellcome Open Res 2019; 3:116. [PMID: 30687790 PMCID: PMC6343222 DOI: 10.12688/wellcomeopenres.14698.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 11/17/2023] Open
Abstract
Background: In light of growing antimalarial drug resistance in Southeast Asia, control programmes have become increasingly focused on malaria elimination, composed of mass drug administration coupled with prompt diagnosis and treatment of symptomatic cases. The key to a successful elimination programme centres on high participation rates in targeted communities, often enhanced by community engagement (CE) efforts. Social science research was conducted to develop a conceptual framework used for CE activities in the Targeted Malaria Elimination programme, as a cross-border operation in Karen/Kayin State, Myanmar. Methods: Data was collected from three main sources: (1) participant observation and semi-structured interviews of CE team members; (2) participant observation and semi-structured interviews with villagers; and (3) records of CE workshops with CE workers conducted as part of the TME programme. Results: Interviews were conducted with 17 CE team members, with 10 participant observations and interviews conducted with villagers and a total of 3 workshops conducted over the course of this pilot programme in 4 villages (November 2013 to October 2014). Thematic analysis was used to construct the nine dimensions for CE in this complex, post-war region: i) history of the people; ii) space; iii) work; iv) knowledge about the world; v) intriguing obstacle (rumour); vi) relationship with the health care system; vii) migration; viii) logic of capitalism influencing openness; and ix) power relations. Conclusions: Conducting CE for the Targeted Malaria Elimination programme was immensely complicated in Karen/Kayin State because of three key realities: heterogeneous terrains, a post-war atmosphere and cross-border operations. These three key realities constituted the nine dimensions, which proved integral to health worker success in conducting CE. Summary of this approach can aid in infectious disease control programmes, such as those using mass drug administration, to engender high rates of community participation.
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Affiliation(s)
- Decha Tangseefa
- Center for Southeast Asian Studies, Kyoto University, Kyoto, 606-8501, Japan
- Faculty of Political Science, Thammasat University, Bangkok, 10200, Thailand
| | - Krishna Monthathip
- Department of International Politics, Aberystwyth University, Aberystwyth, West Wales, SY23 3FL, UK
| | | | - Andrea König
- Peace Information Center, Faculty of Political Science, Thammasat University, Bangkok, 10200, Thailand
| | - Ladda Kajeechiwa
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Suphak Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Saw Win Tun
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Kayin Ma
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Ahmar Hashmi
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Phaik Yeong Cheah
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Lorenz von Seidlein
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
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17
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von Seidlein L, Peto TJ, Landier J, Nguyen TN, Tripura R, Phommasone K, Pongvongsa T, Lwin KM, Keereecharoen L, Kajeechiwa L, Thwin MM, Parker DM, Wiladphaingern J, Nosten S, Proux S, Corbel V, Tuong-Vy N, Phuc-Nhi TL, Son DH, Huong-Thu PN, Tuyen NTK, Tien NT, Dong LT, Hue DV, Quang HH, Nguon C, Davoeung C, Rekol H, Adhikari B, Henriques G, Phongmany P, Suangkanarat P, Jeeyapant A, Vihokhern B, van der Pluijm RW, Lubell Y, White LJ, Aguas R, Promnarate C, Sirithiranont P, Malleret B, Rénia L, Onsjö C, Chan XH, Chalk J, Miotto O, Patumrat K, Chotivanich K, Hanboonkunupakarn B, Jittmala P, Kaehler N, Cheah PY, Pell C, Dhorda M, Imwong M, Snounou G, Mukaka M, Peerawaranun P, Lee SJ, Simpson JA, Pukrittayakamee S, Singhasivanon P, Grobusch MP, Cobelens F, Smithuis F, Newton PN, Thwaites GE, Day NPJ, Mayxay M, Hien TT, Nosten FH, Dondorp AM, White NJ. The impact of targeted malaria elimination with mass drug administrations on falciparum malaria in Southeast Asia: A cluster randomised trial. PLoS Med 2019; 16:e1002745. [PMID: 30768615 PMCID: PMC6377128 DOI: 10.1371/journal.pmed.1002745] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The emergence and spread of multidrug-resistant Plasmodium falciparum in the Greater Mekong Subregion (GMS) threatens global malaria elimination efforts. Mass drug administration (MDA), the presumptive antimalarial treatment of an entire population to clear the subclinical parasite reservoir, is a strategy to accelerate malaria elimination. We report a cluster randomised trial to assess the effectiveness of dihydroartemisinin-piperaquine (DP) MDA in reducing falciparum malaria incidence and prevalence in 16 remote village populations in Myanmar, Vietnam, Cambodia, and the Lao People's Democratic Republic, where artemisinin resistance is prevalent. METHODS AND FINDINGS After establishing vector control and community-based case management and following intensive community engagement, we used restricted randomisation within village pairs to select 8 villages to receive early DP MDA and 8 villages as controls for 12 months, after which the control villages received deferred DP MDA. The MDA comprised 3 monthly rounds of 3 daily doses of DP and, except in Cambodia, a single low dose of primaquine. We conducted exhaustive cross-sectional surveys of the entire population of each village at quarterly intervals using ultrasensitive quantitative PCR to detect Plasmodium infections. The study was conducted between May 2013 and July 2017. The investigators randomised 16 villages that had a total of 8,445 residents at the start of the study. Of these 8,445 residents, 4,135 (49%) residents living in 8 villages, plus an additional 288 newcomers to the villages, were randomised to receive early MDA; 3,790 out of the 4,423 (86%) participated in at least 1 MDA round, and 2,520 out of the 4,423 (57%) participated in all 3 rounds. The primary outcome, P. falciparum prevalence by month 3 (M3), fell by 92% (from 5.1% [171/3,340] to 0.4% [12/2,828]) in early MDA villages and by 29% (from 7.2% [246/3,405] to 5.1% [155/3,057]) in control villages. Over the following 9 months, the P. falciparum prevalence increased to 3.3% (96/2,881) in early MDA villages and to 6.1% (128/2,101) in control villages (adjusted incidence rate ratio 0.41 [95% CI 0.20 to 0.84]; p = 0.015). Individual protection was proportional to the number of completed MDA rounds. Of 221 participants with subclinical P. falciparum infections who participated in MDA and could be followed up, 207 (94%) cleared their infections, including 9 of 10 with artemisinin- and piperaquine-resistant infections. The DP MDAs were well tolerated; 6 severe adverse events were detected during the follow-up period, but none was attributable to the intervention. CONCLUSIONS Added to community-based basic malaria control measures, 3 monthly rounds of DP MDA reduced the incidence and prevalence of falciparum malaria over a 1-year period in areas affected by artemisinin resistance. P. falciparum infections returned during the follow-up period as the remaining infections spread and malaria was reintroduced from surrounding areas. Limitations of this study include a relatively small sample of villages, heterogeneity between villages, and mobility of villagers that may have limited the impact of the intervention. These results suggest that, if used as part of a comprehensive, well-organised, and well-resourced elimination programme, DP MDA can be a useful additional tool to accelerate malaria elimination. TRIAL REGISTRATION ClinicalTrials.gov NCT01872702.
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Affiliation(s)
- Lorenz von Seidlein
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas J. Peto
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jordi Landier
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Institut de Recherche pour le Développement, Aix–Marseille University, INSERM, SESSTIM, Marseille, France
| | - Thuy-Nhien Nguyen
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Rupam Tripura
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Koukeo Phommasone
- Lao–Oxford–Mahosot Hospital–Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- Amsterdam Institute for Global Health & Development, Amsterdam, The Netherlands
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Savannakhet Province, Lao People’s Democratic Republic
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Lilly Keereecharoen
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Ladda Kajeechiwa
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Daniel M. Parker
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Department of Population Health and Disease Prevention, University of California, Irvine, Irvine, California, United States of America
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Suphak Nosten
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Vincent Corbel
- Maladies Infectieuses et Vecteurs: Écologie, Génétique, Evolution et Contrôle, Institut de Recherche pour le Développement, Université Montpellier, Montpellier, France
| | - Nguyen Tuong-Vy
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Truong Le Phuc-Nhi
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Do Hung Son
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Pham Nguyen Huong-Thu
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Kim Tuyen
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Nguyen Thanh Tien
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Le Thanh Dong
- Institute of Malariology, Parasitology, and Entomology, Ho Chi Minh City, Vietnam
| | - Dao Van Hue
- Center for Malariology, Parasitology and Entomology, Ninh Thuan Province, Vietnam
| | - Huynh Hong Quang
- Institute of Malariology, Parasitology, and Entomology, Quy Nhon, Vietnam
| | - Chea Nguon
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | - Huy Rekol
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Bipin Adhikari
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Gisela Henriques
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Pathogen Molecular Biology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Panom Phongmany
- Savannakhet Provincial Health Department, Savannakhet Province, Lao People’s Democratic Republic
| | - Preyanan Suangkanarat
- Lao–Oxford–Mahosot Hospital–Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
| | - Atthanee Jeeyapant
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Benchawan Vihokhern
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Rob W. van der Pluijm
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Lisa J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ricardo Aguas
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Cholrawee Promnarate
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- WWARN Asia Regional Centre, Mahidol University, Bangkok, Thailand
| | - Pasathorn Sirithiranont
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Benoit Malleret
- Department of Microbiology & Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Singapore Immunology Network, Agency for Science, Technology and Research, Singapore
| | - Laurent Rénia
- Singapore Immunology Network, Agency for Science, Technology and Research, Singapore
| | - Carl Onsjö
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Faculty of Medicine and Health Sciences, Linköping University, Linköping, Linköping, Sweden
| | - Xin Hui Chan
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jeremy Chalk
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Olivo Miotto
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - Krittaya Patumrat
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kesinee Chotivanich
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Borimas Hanboonkunupakarn
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Podjanee Jittmala
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nils Kaehler
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Christopher Pell
- Amsterdam Institute for Global Health & Development, Amsterdam, The Netherlands
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- WWARN Asia Regional Centre, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Georges Snounou
- CEA–Université Paris Sud 11–INSERM U1184, IDMIT, Direction de la Recherche Fondamentale, Commissariat à l’Énergie Atomique et aux Énergies Alternatives, Fontenay-aux-Roses, France
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Pimnara Peerawaranun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sue J. Lee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Sasithon Pukrittayakamee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Royal Society of Thailand, Bangkok, Thailand
| | - Pratap Singhasivanon
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Martin P. Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank Cobelens
- Amsterdam Institute for Global Health & Development, Amsterdam, The Netherlands
| | | | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao–Oxford–Mahosot Hospital–Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
| | - Guy E. Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programmes, Ho Chi Minh City, Vietnam
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mayfong Mayxay
- Lao–Oxford–Mahosot Hospital–Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao People’s Democratic Republic
| | - Tran Tinh Hien
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Institut de Recherche pour le Développement, Aix–Marseille University, INSERM, SESSTIM, Marseille, France
| | - Francois H. Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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18
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Adhikari B, Pell C, Phommasone K, Soundala X, Kommarasy P, Pongvongsa T, Henriques G, Day NPJ, Mayxay M, Cheah PY. Elements of effective community engagement: lessons from a targeted malaria elimination study in Lao PDR (Laos). Glob Health Action 2018; 10:1366136. [PMID: 28914184 PMCID: PMC5645700 DOI: 10.1080/16549716.2017.1366136] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Mass drug (antimalarial) administration (MDA) is currently under study in Southeast Asia as part of a package of interventions referred to as targeted malaria elimination (TME). This intervention relies on effective community engagement that promotes uptake and adherence in target communities (above 80%). Objective: Based on the experienced of designing and implementing the community engagement for TME in Laos, in this article we aim to present the elements of effective community engagement for mass antimalarial administration. Methods: The design and implementation of community engagement, which took place from September 2015 to August 2016 was recorded as field notes, meeting minutes and photographs. These data underwent qualitative content analysis. Results: The community engagement strategy that accompanied TME in Laos was successful in terms of contributing to high levels of participation in mass anti-malarial administration (above 85%). Based on the experience of designing and implementing the community engagement, five key elements were identified: (1) stakeholder and authority engagement, which proceeded from national level, to regional/district and local level; (2) local human resources, particularly the recruitment of local volunteers who were integral to the design and implementation of activities in the study villages; (3) formative research, to rapidly gain insight into the local social and economic context; (4) responsiveness whereby the approach was adapted according to the needs of the community and their responses to the various study components; and (5) sharing control/leadership with the community in terms of decisions on the organization of TME activities. Conclusions: The community engagement that accompanied TME in Laos had to deal with challenges of implementing a complex study in remote and linguistically isolated villages. Despite these challenges, the study recorded high population coverage. Lessons learnt from this experience are useful for studies and intervention programs in diverse contexts.
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Affiliation(s)
- Bipin Adhikari
- a Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , Churchill Hospital , Oxford , UK.,c Kellogg College , University of Oxford , Oxford , UK
| | - Christopher Pell
- d Centre for Social Science and Global Health , University of Amsterdam , Amsterdam , The Netherlands.,e Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands
| | - Koukeo Phommasone
- f Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU) , Microbiology Laboratory , Vientiane , Laos
| | - Xayaphone Soundala
- f Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU) , Microbiology Laboratory , Vientiane , Laos
| | - Palingnaphone Kommarasy
- f Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU) , Microbiology Laboratory , Vientiane , Laos
| | | | - Gisela Henriques
- a Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Nicholas P J Day
- a Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , Churchill Hospital , Oxford , UK
| | - Mayfong Mayxay
- b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , Churchill Hospital , Oxford , UK.,f Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU) , Microbiology Laboratory , Vientiane , Laos.,h Faculty of Postgraduate Studies , University of Health Sciences , Vientiane , Laos
| | - Phaik Yeong Cheah
- a Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , Churchill Hospital , Oxford , UK
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19
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Taffon P, Rossi G, Kindermans JM, Van den Bergh R, Nguon C, Debackere M, Vernaeve L, De Smet M, Venables E. 'I could not join because I had to work for pay.': A qualitative evaluation of falciparum malaria pro-active case detection in three rural Cambodian villages. PLoS One 2018; 13:e0195809. [PMID: 29649317 PMCID: PMC5897025 DOI: 10.1371/journal.pone.0195809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/29/2018] [Indexed: 11/19/2022] Open
Abstract
Background Pro-active case detection (Pro-ACD), in the form of voluntary screening and treatment (VSAT) following community mobilisation about ‘asymptomatic malaria’, is currently being evaluated as a tool for Plasmodium falciparum elimination in Preah Vihear Province, Cambodia. Methods A qualitative study was conducted to explore community understanding, perceptions, expectations and acceptability of the Pro-ACD intervention in order to identify aspects that could be improved in future Pro-ACD activities. This was ancillary to a three-round VSAT campaign, carried out in three villages between December 2015 and March 2016. Qualitative data collection began shortly after the end of the three rounds of screening. Purposive sampling was used to select participants. Nine focus group discussions with participants (n = 46) and non-participants (n = 40) in the Pro-ACD screening were conducted, in addition to in-depth interviews with key village figures (n = 9). Results Health promotion messages were well delivered and received, but it was difficult for many villagers to understand the messages around ‘asymptomatic malaria’. Overall, villagers and village leaders had a positive opinion about the VSAT intervention. Acceptability was high, as a direct consequence of favourable perceptions towards the screening activity: the Pro-ACD intervention was seen by the local population as an effective, inexpensive, reliable and readily available tool to protect individuals and the community from the insurgence of malaria. Physical absence and lack of time (both linked to work-related activities) were the main reasons for non-participation. Conclusions Although VSAT was generally well perceived and accepted, the ‘time factor’ related to the need to satisfy essential daily subsistence requirements played a significant role in determining participation in the screening. More well-adapted and meaningful Pro-ACD approaches could be implemented by improving the timing of the testing activites, and strengthening community participation and engagement to increase acceptability.
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Affiliation(s)
| | | | | | | | - Chea Nguon
- Centre for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | | | - Martin De Smet
- Médecins Sans Frontières, Operational Centre Belgium, Brussels, Belgium
| | - Emilie Venables
- Médecins Sans Frontières, Operational Centre Belgium, Brussels, Belgium
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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20
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Adhikari B, Phommasone K, Kommarasy P, Soundala X, Souvanthong P, Pongvongsa T, Henriques G, Newton PN, White NJ, Day NPJ, Dondorp AM, von Seidlein L, Mayxay M, Cheah PY, Pell C. Why do people participate in mass anti-malarial administration? Findings from a qualitative study in Nong District, Savannakhet Province, Lao PDR (Laos). Malar J 2018; 17:15. [PMID: 29316932 PMCID: PMC5761145 DOI: 10.1186/s12936-017-2158-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/23/2017] [Indexed: 01/01/2023] Open
Abstract
Background As a part of targeted malaria elimination (TME) in the Greater Mekong Sub-region (GMS), mass drug administration (MDA) with anti-malarials was conducted in four villages in Nong District, Savannakhet Province, Lao PDR (Laos). A high proportion of the target population participated in the MDA, with over 87% agreeing to take the anti-malarial. Drawing on qualitative data collected alongside the MDA, this article explores the factors that led to this high population coverage. Methods Qualitative data collection methods included observations, which were recorded in field notes, focus group discussions (FGDs), and semi-structured interviews (SSIs). Data were collected on local context, MDA-related knowledge, attitudes and perceptions. FGDs and SSIs were audio-recorded, transcribed and translated to English. All transcriptions and field notes underwent qualitative content analysis using QSR NVivo. Results Respondents recognized malaria as a health concern and described the need for a malaria control program. The risk of malaria including asymptomatic infection was explained in terms of participants’ work in forest and fields, and poor hygiene. During the MDA rounds, there was an improvement in knowledge on the concept of asymptomatic malaria, the rationale of MDA and the blood test. In all four villages, poverty affected access to healthcare and the provision of free care by TME was highly appreciated. TME was jointly undertaken by research staff and local volunteers. Authorities were involved in all TME activities. Lao Theung communities were cohesive and community members tended to follow each other’s behaviour closely including participation in MDA. Factors such as understanding the concept and rationale of the study, free health care, collaboration with the village volunteers, support from authorities and cohesive communities contributed in building trust and high population coverage in MDA. Conclusion Future malaria control programmes can become successful in achieving the high coverage in MDAs drawing from the success of TME in Laos. A high population coverage in TME was a combination of various factors that included the community engagement to promote the concept and rationale of MDA for asymptomatic malaria in addition to their baseline understanding of malaria as a health concern, provision of free primary health care, partnering of the research with local volunteers and authorities, building social relationship with community members and the cohesive nature of the communities boosted the trust and participation in MDA. Electronic supplementary material The online version of this article (10.1186/s12936-017-2158-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,Kellogg College, University of Oxford, Oxford, UK
| | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Palingnaphone Kommarasy
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Xayaphone Soundala
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Phonesavanh Souvanthong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Savannakhet, Savannakhet Province, Laos
| | - Gisela Henriques
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos.,Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK. .,The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
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21
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Adhikari B, Phommasone K, Pongvongsa T, Kommarasy P, Soundala X, Henriques G, White NJ, Day NPJ, Dondorp AM, von Seidlein L, Cheah PY, Pell C, Mayxay M. Factors associated with population coverage of targeted malaria elimination (TME) in southern Savannakhet Province, Lao PDR. Malar J 2017; 16:424. [PMID: 29061133 PMCID: PMC5653989 DOI: 10.1186/s12936-017-2070-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/16/2017] [Indexed: 11/17/2022] Open
Abstract
Background Targeted malaria elimination (TME) in Lao PDR (Laos) included three rounds of mass drug administrations (MDA) against malaria followed by quarterly blood surveys in two villages in Nong District at Savannakhet Province. The success of MDA largely depends upon the efficacy of the anti-malarial drug regimen, local malaria epidemiology and the population coverage. In order to explore the reasons for participation in TME, a quantitative survey was conducted after the completion of the three rounds of MDA. Methods The survey was conducted in two villages with a total of 158 households in July and August 2016. Among the 973 villagers eligible for participation in the MDA, 158 (16.2%) adults (> 18 years) were selected, one each from every household for the interviews using a quantitative questionnaire. Results 150/158 (94.9%) respondents participated at least in one activity (taking medicine or testing their blood) of TME. 141/150 (94.0%) respondents took part in the MDA and tested their blood in all three rounds. 17/158 (10.7%) were partial or non-participants in three rounds of MDA. Characteristics of respondents which were independently associated with completion of three rounds of MDA included: attending TME meetings [AOR = 12.0 (95% CI 1.1–20.5) (p = 0.03)], knowing that malaria can be diagnosed through blood tests [AOR = 5.6 (95% CI 1.0–32.3) (p = 0.05)], all members from household participated [AOR = 4.2 (95% CI 1.3–14.0) (p = 0.02)], liking all aspects of TME [AOR = 17.2 (95% CI 1.6–177.9) (p = 0.02)] and the perception that TME was important [AOR = 14.9 (95% CI 1.3–171.2) (p = 0.03)]. Conclusion Complete participation in TME was significantly associated with participation in community engagement activities, knowledge that the blood tests were for malaria diagnosis, family members’ participation at TME and perceptions that TME was worthwhile. A responsive approach to community engagement that includes formative research and the involvement of community members may increase the uptake of the intervention. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2070-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK. .,Kellogg College, University of Oxford, Oxford, UK.
| | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Savannakhet, Savannakhet Province, Laos
| | - Palingnaphone Kommarasy
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Xayaphone Soundala
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos
| | - Gisela Henriques
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Vientiane, Laos.,Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos
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22
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Pell C, Tripura R, Nguon C, Cheah P, Davoeung C, Heng C, Dara L, Sareth M, Dondorp A, von Seidlein L, Peto TJ. Mass anti-malarial administration in western Cambodia: a qualitative study of factors affecting coverage. Malar J 2017; 16:206. [PMID: 28526019 PMCID: PMC5438518 DOI: 10.1186/s12936-017-1854-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/09/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mass anti-malarial administration has been proposed as a key component of the Plasmodium falciparum malaria elimination strategy in the Greater Mekong sub-Region. Its effectiveness depends on high levels of coverage in the target population. This article explores the factors that influenced mass anti-malarial administration coverage within a clinical trial in Battambang Province, western Cambodia. METHODS Qualitative data were collected through semi-structured interviews and focus group discussions with villagers, in-depth interviews with study staff, trial drop-outs and refusers, and observations in the communities. Interviews were audio-recorded, transcribed and translated from Khmer to English for qualitative content analysis using QSR NVivo. RESULTS Malaria was an important health concern and villagers reported a demand for malaria treatment. This was in spite of a fall in incidence over the previous decade and a lack of familiarity with asymptomatic malaria. Participants generally understood the overall study aim and were familiar with study activities. Comprehension of the study rationale was however limited. After the first mass anti-malarial administration, seasonal health complaints that participants attributed to the anti-malarial as "side effects" contributed to a decrease of coverage in round two. Staff therefore adapted the community engagement approach, bringing to prominence local leaders in village meetings. This contributed to a subsequent increase in coverage. CONCLUSION Future mass anti-malarial administration must consider seasonal disease patterns and the importance of local leaders taking prominent roles in community engagement. Further research is needed to investigate coverage in scenarios that more closely resemble implementation i.e. without participation incentives, blood sampling and free healthcare.
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Affiliation(s)
- Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Rupam Tripura
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Chea Nguon
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Phaikyeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Chan Davoeung
- Battambang Provincial Health Department, Krong Battambang, Cambodia
| | - Chhouen Heng
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Lim Dara
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Ma Sareth
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Arjen Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Thomas J. Peto
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Community engagement and the social context of targeted malaria treatment: a qualitative study in Kayin (Karen) State, Myanmar. Malar J 2017; 16:75. [PMID: 28196536 PMCID: PMC5310060 DOI: 10.1186/s12936-017-1718-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 02/03/2017] [Indexed: 12/15/2022] Open
Abstract
Background The spread of artemisinin-resistance in Plasmodium falciparum is a threat to current global malaria control initiatives. Targeted malaria treatment (TMT), which combines mass anti-malarial administration with conventional malaria prevention and control measures, has been proposed as a strategy to tackle this problem. The effectiveness of TMT depends on high levels of population coverage and is influenced by accompanying community engagement activities and the local social context. The article explores how these factors influenced attitudes and behaviours towards TMT in Kayin (Karen) State, Myanmar. Methods Semi-structured interviews were conducted with villagers from study villages (N = 31) and TMT project staff (N = 14) between March and July 2015. Results Community engagement consisted of a range of activities to communicate the local malaria situation (including anti-malarial drug resistance and asymptomatic malaria), the aims of the TMT project, and its potential benefits. Community engagement was seen by staff as integral to the TMT project as a whole and not a sub-set of activities. Attitudes towards TMT (including towards community engagement) showed that developing trusting relationships helped foster participation. After initial wariness, staff received hospitality and acceptance among villagers. Offering healthcare alongside TMT proved mutually beneficial for the study and villagers. A handful of more socially-mobile and wealthy community members were reluctant to participate. The challenges of community engagement included time constraints and the isolation of the community with its limited infrastructure and a history of conflict. Conclusions Community engagement had to be responsive to the local community even though staff faced time constraints. Understanding the social context of engagement helped TMT to foster respectful and trusting relationships. The complex relationship between the local context and community engagement complicated evaluation of the community strategy. Nonetheless, the project did record high levels of population coverage.
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