How are the village health volunteers deliver malaria testing and treatment services and what are the challenges they are facing? A mixed methods study in Myanmar

Radical cure for Plasmodium vivax malaria after G6PD qualitative testing in four provinces in Cambodia, results from Phase I implementation

BACKGROUND

Cambodia aims to eliminate all forms of malaria by 2025. In 2020, 90% of all malaria cases were Plasmodium vivax. Thus, preventing P. vivax and relapse malaria is a top priority for elimination. 14-day primaquine, a World Health Organization-recommended radical cure treatment regimen, specifically targets dormant hypnozoites in the liver to prevent relapse. Cambodia introduced P. vivax radical cure with primaquine after glucose-6-phosphate dehydrogenase (G6PD) qualitative testing in 2019. This paper presents Cambodia's radical cure Phase I implementation results and assesses the safety, effectiveness, and feasibility of the programme prior to nationwide scale up.

METHODS

Phase I implementation was carried out in 88 select health facilities (HFs) across four provinces. Males over 20kgs with confirmed P. vivax or mixed (P. vivax and Plasmodium falciparum) infections were enrolled. A descriptive analysis evaluated the following: successful referral to health facilities, G6PD testing results, and self-reported 14-day treatment adherence. P. vivax incidence was compared before and after radical cure rollout and a controlled interrupted time series analysis compared the estimated relapse rate between implementation and non-implementation provinces before and after radical cure.

RESULTS

In the 4 provinces from November 2019 to December 2020, 3,239 P. vivax/mixed infections were reported, 1,282 patients underwent G6PD deficiency testing, and 959 patients received radical cure, achieving 29.6% radical cure coverage among all P. vivax/mixed cases and 98.8% coverage among G6PD normal patients. Among those who initiated radical cure, 747 patients (78%) completed treatment. Six patients reported side effects. In implementation provinces, an average 31.8 relapse cases per month were estimated signaling a 90% (286 cases) reduction in relapse compared to what would be expected if radical cure was not implemented.

CONCLUSIONS

Plasmodium vivax radical cure is a crucial tool for malaria elimination in Cambodia. The high coverage of radical cure initiation and adherence among G6PD normal patients demonstrated the high feasibility of providing radical cure at point of care in Cambodia. Incomplete referral from community to HFs and limited capacity of HF staff to conduct G6PD testing in high burden areas led to lower coverage of G6PD testing. Phase I implementation informed approaches to improve referral completion and patient adherence during the nationwide expansion of radical cure in 2021.

Prospects for the development of community-based care in remote rural areas: a stakeholder analysis in Laos

BACKGROUND

Community-based health programmes have been a cornerstone of primary care in Laos for decades. The study presented here aimed to document prospects for the development of current programmes, considering perceptions about health and health care priorities in the communities, implementation challenges, the policy landscape and opportunities associated with the availability of new technologies.

METHODS

The research design primarily involved qualitative in-depth interviews with stakeholders (n = 35) responsible for the planning, management, or implementation of community-based care in Laos at different levels of the health system. These included health managers at central departments or institutes of the Ministry of Health, provincial health departments, district health offices, heads of health centres, village health volunteers, community representatives, and international stakeholders.

RESULTS

There was consensus that service delivery is still a challenge in many areas, due to geographic inaccessibility of health facilities, communication barriers, health-seeking behaviour, trust, and gender discrimination, particularly among ethnic minorities. In these settings, community health workers have the potential to extend the reach of the formal health system, acting as cultural brokers across sectors of society, ethnicities, and worldviews. To maximise impact, planners need to carefully consider the implementation model, financing arrangements, health system integration, and changing health priorities in the communities.

CONCLUSIONS

This study examined challenges to, and opportunities for, the expansion and health system integration of community-based care in Laos. Further development and horizontal integration of community-based care remains a complex financing and governance challenge, although the renewed emphasis on primary care and the ongoing process of decentralisation provide a favourable policy environment in the country to sustain and potentially expand existing programmes.

Interventions for promoting patients' adherence to 14-day primaquine treatment in a highly malaria-endemic township in Myanmar: a qualitative study among key stakeholders

BACKGROUND

Plasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients' commitment to PQ treatment in a highly malaria-endemic township in Myanmar.

METHODS

A qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis.

RESULTS

Responsible individuals from different levels of the Myanmar National Malaria Control Programme participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community's malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted.

CONCLUSION

In rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

Interventions for promoting patients' adherence to 14-day primaquine treatment in a highly malaria-endemic township in Myanmar: A qualitative study among key stakeholders

Background

Plasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients' commitment to PQ treatment in a highly malaria-endemic township in Myanmar.

Methods

A qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis.

Results

Responsible individuals from different levels of the Myanmar National Malaria Control Program participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community's malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted.

Conclusion

In rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

Narrative Review of the Control and Prevention of Knowlesi Malaria

Despite the reduction in the number of cases of human malaria throughout the world, the incidence rate of knowlesi malaria is continuing to rise, especially in Southeast Asia. The conventional strategies for the prevention and control of human malaria can provide some protection against knowlesi malaria. Despite the numerous studies on the risk factors and the innovative methods that may be used to prevent and control the vectors of Plasmodium knowlesi, the incidence rate remains high. An integrated approach that includes environmental intervention should be adopted in order to ensure the successful control of zoonotic malaria. A combination of personal-level protection, vector control and environmental control may mitigate the risk of Plasmodium knowlesi transmission from macaques to humans and, ultimately, reduce the incidence rate of knowlesi malaria.

Perspectives of health and community stakeholders on community-delivered models of malaria elimination in Lao People’s Democratic Republic: A qualitative study

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.

Evaluation of the effectiveness and cost effectiveness of a Community-delivered Integrated Malaria Elimination (CIME) model in Myanmar: protocol for an open stepped-wedge cluster-randomised controlled trial

INTRODUCTION

In the Greater Mekong Subregion, community health workers, known as malaria volunteers, have played a key role in reducing malaria in the control phase, providing essential malaria services in areas with limited formal healthcare. However, the motivation and social role of malaria volunteers, and testing rates, have declined with decreasing malaria burden and reorientation of malaria programmes from control to elimination. Provision of additional interventions for common health concerns could help sustain the effectiveness of volunteers and maintain malaria testing rates required for malaria elimination accreditation by the WHO.

METHODS AND ANALYSIS

The Community-delivered Integrated Malaria Elimination (CIME) volunteer model, integrating interventions for malaria, dengue, tuberculosis, childhood diarrhoea and malaria Rapid Diagnostic Test (RDT)-negative fever, was developed based on global evidence and extensive stakeholder consultations. An open stepped-wedge cluster-randomised controlled trial, randomised at the volunteer level, will be conducted over 6 months to evaluate the effectiveness of the CIME model in Myanmar. One hundred and forty Integrated Community Malaria Volunteers (ICMVs, current model of care) providing malaria services in 140 villages will be retrained as CIME volunteers (intervention). These 140 ICMVs/villages will be grouped into 10 blocks of 14 villages, with blocks transitioned from control (ICMV) to intervention states (CIME), fortnightly, in random order, following a 1-week training and transition period. The primary outcome of the trial is blood examination rate determined by the number of malaria RDTs performed weekly. Difference in rates will be estimated across village intervention and control states using a generalised linear mixed modelling analytical approach with maximum likelihood estimation.

ETHICS AND DISSEMINATION

The study was approved by Institutional Review Board, Myanmar Department of Medical Research (Ethics/DMR/2020/111) and Alfred Hospital Ethics Review Committee, Australia (241/20). Findings will be disseminated in peer-review journals, conferences and regional, national and local stakeholder meetings.

TRIAL REGISTRATION NUMBER

NCT04695886.

Optimizing Myanmar's community-delivered malaria volunteer model: a qualitative study of stakeholders' perspectives

BACKGROUND

In parallel with the change of malaria policy from control to elimination and declines in the malaria burden in Greater Mekong Sub-region, the motivation and social role of malaria volunteers has declined. To address this public health problem, in Myanmar, the role and responsibilities of malaria volunteers have been transformed into integrated community malaria volunteers (ICMV), that includes the integration of activities for five additional diseases (dengue, lymphatic filariasis, tuberculosis, HIV/AIDS and leprosy) into their current activities. However, this transformation was not evidence-based and did not consider inputs of different stakeholders. Therefore, qualitative stakeholder consultations were performed to optimize future malaria volunteer models in Myanmar.

METHODS

Semi-structured interviews were conducted with key health stakeholders from the Myanmar Ministry of Health and Sports (MoHS) and malaria implementing partners to obtain their perspectives on community-delivered malaria models. A qualitative descriptive approach was used to explore the experiences of the stakeholders in policymaking and programme implementation. Interview topic guides were used during the interviews and inductive thematic data analysis was performed.

RESULTS

While ICMVs successfully provided malaria services in the community, the stakeholders considered the ICMV model as not optimal and suggested that many aspects needed to be improved including better training, supervision, support, and basic health staff's recognition for ICMVs. Stakeholders believe that the upgraded ICMV model could contribute significantly to achieving malaria elimination and universal health care in Myanmar.

DISCUSSION AND CONCLUSION

In the context of high community demand for non-malaria treatment services from volunteers, the integrated volunteer service package must be developed carefully in order to make it effective in malaria elimination programme and to contribute in Myanmar's pathway to universal health coverage (UHC), but without harming the community. An evidenced-based, community-delivered and preferred model, that is also accepted by the MoHS, is yet to be developed to effectively contribute to achieving malaria elimination and UHC goals in Myanmar by 2030.

Performance of Malaria Volunteers regarding Malaria Control Activities in Southeastern Myanmar: A Study in the Areas under Coverage of an Ethnic Health Organization

Malaria volunteers (MVs) play an essential role in resolving malaria problems by delivering greater access to diagnosis and treatment services, mainly for the underserved community residing in hard-to-reach rural areas. The Karen Department of Health and Welfare (KDHW) has implemented community-based malaria control activities among the ethnic minorities in southeastern Myanmar by promoting the roles of MVs. This study aimed to explore the factors influencing the performance of MVs regarding malaria control activities in the area. From July to August 2019, a cross-sectional study was conducted in 12 townships of southeastern Myanmar under the umbrella of the KDHW malaria project. A total of 140 MVs were employed as study participants. Data were collected through face-to-face interviews using a structured questionnaire. For data analyses, descriptive statistics, chi-squared tests, and logistics regression models were applied. More than half of the MVs perceived a good level of performance on malaria control activities. A higher level of performance has been observed among the MVs who had another job (AOR: 1.9, 95% CI: 1.2–3.9), those experienced in health-related fields (AOR: 1.9, 95% CI: 1.4–4.9), who received good community support (AOR: 2.1, 95% CI: 1.3–10.9), who were volunteers beyond three years (AOR: 4.0, 95% CI: 2.8–9.2), and whose family income totaled over 500,000 MMK (AOR: 2.8, 95% CI: 1.6–4.2). The results mentioned the characteristics which should be prioritized in recruiting MVs. MV network and their workforce need to be nurtured by encouraging community support. For performance sustainability, attractive incentive schemes or a salary should be subsidized in support of their livelihoods.

Community demand for comprehensive primary health care from malaria volunteers in South-East Myanmar: a qualitative study

BACKGROUND

Malaria volunteers have contributed significantly to malaria control achieving a reduction of annual parasite incidence to pre-elimination levels in several townships across Myanmar. However, the volunteers' role is changing as Myanmar transitions from a malaria control to elimination programme and towards the goal of universal health coverage. The aim of the study is to explore the perspectives of community leaders, members and malaria volunteers in South-East Myanmar on community-delivered models to inform an optimal design that targets malaria elimination in the context of primary health care in Myanmar.

METHODS

Qualitative methods including focus group discussions (FGDs) with community members and current or ex-malaria volunteers, and participatory workshops with community leaders were conducted. All data collection tools were pilot tested with similar participants. The FGDs were stratified into male and female participants in consideration of diverse gender roles among the ethnic groups of Myanmar. Data saturation was the key cut-off point to cease recruitment of participants. Inductive thematic analysis was used.

RESULTS

Community members were willing to be tested for malaria because they were concerned about the consequences of malaria although they were aware that malaria prevalence is low in their villages. Malaria volunteers were the main service providers for malaria and other infectious diseases in the community. Apart from malaria, the community identified common health problems such as the flu (fever, sneezing and coughing), diarrhoea, skin infections and tuberculosis as priority diseases in this order. Incorporating preventive, and whenever possible curative, services for those diseases into the current malaria volunteer model was recommended.

DISCUSSION AND CONCLUSION

There was a gap between the communities' expectations of health services and the health services currently being delivered by volunteers in the community that highlights the need for reassessment and reform of the volunteer model in the changing context. An evidence-based, community preferred, pragmatic community-delivered integrated model should be constructed based on the context of malaria elimination and progressing towards universal health coverage in Myanmar.

Quality of Malaria Treatment Provided under 'Better Health Together' Project in Ethnic Communities of Myanmar: How Are We Performing?

Malaria accounted for 18% of all deaths in the ethnic communities of Myanmar. In this cross-sectional study, we assessed the extent of and factors associated with receipt of quality malaria treatment services provided by integrated community malaria volunteer (ICMV) under six ethnic health organisations. Data of people with malaria diagnosed by rapid diagnostic tests during 2017–2018 were extracted from the ICMV registers. Documentation of prescribing a complete course of drugs was used to assess quality. Of 2881 people with malaria, village-based ICMV diagnosed and treated 2279 (79%) people. Overall, 2726 (95%) people received correct drugs in the correct dose and adequate duration appropriate to malaria species, age and pregnancy status while 1285 (45%) people received ‘correct and timely (within 24 h of fever)’ treatment. Children under five years, those with severe malaria, mixed infection and falciparum malaria were less likely to receive the correct treatment. When compared to health posts, village-based ICMVs and mobile teams performed better in providing correct treatment and mobile teams in providing ‘correct and timely’ treatment. This calls for ensuring the early presentation of people to health workers within 24 h of undifferentiated fever through health promotion initiatives. Future studies should assess adherence to medication and clinical improvement.

Prospects and strategies for malaria elimination in the Greater Mekong Sub-region: a qualitative study

BACKGROUND

As malaria elimination becomes a goal in malaria-endemic nations, questions of feasibility become critical. This article explores the potential challenges associated with this goal and future strategies for malaria elimination in the Greater Mekong Sub-region.

METHODS

Thirty-two semi-structured interviews were conducted with policy makers (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 QSR NVivo.

RESULTS

All respondents described current malaria control and elimination strategies, such as case detection and management, prevention and strengthening of surveillance systems as critical and of equal priority. Aware of the emergence of multi-drug resistance in the GMS, researchers and policy makers outlined the need for additional elimination tools. As opposed to a centralized strategy, more targeted and tailored approaches to elimination were recommended. These included targeting endemic areas, consideration for local epidemiology and malaria species, and strengthening the peripheral health system. A decline in malaria transmission could lead to complacency amongst funders and policy makers resulting in a reduction or discontinuation of support for malaria elimination. Strong commitment of policymakers combined with strict monitoring and supervision by funders were considered pivotal to successful elimination programmes.

CONCLUSION

Against a backdrop of increasing anti-malarial resistance and decreasing choices of anti-malarial regimens, policy makers and researchers stressed the urgency of finding new malaria elimination strategies. There was consensus that multi-pronged strategies and approaches are needed, that no single potential tool/strategy can be appropriate to all settings. Hence there is a need to customize malaria control and elimination strategies based on the better surveillance data.

Factors influencing performance of community-based health volunteers' activities in the Kassena-Nankana Districts of Northern Ghana

BACKGROUND

An increasing demand for health care services and getting health care closer to doorsteps of communities has made health managers to use trained community-based health volunteers to support in providing health services to people in rural communities. Community volunteerism in Ghana has been identified as an effective strategy in the implementation of Primary Health Care activities since 1970s. However, little is known about the performance of these volunteers engaged in health interventions activities at the community level. This study assessed the level of performance and factors that affect the performance of health volunteers' activities in Northern Ghana.

METHODS

This was a cross-sectional study using quantitative method of data collection. Two hundred structured interviews were conducted with health volunteers. Data collectors visited health volunteers at home and conducted the interviews after informed consent was obtained. STATA Version 11.2 was used to analyze the data. Descriptive statistics were used to assess the level of performance of the health volunteers. Multiple logistic regression models were then used to assess factors that influence the performance of health volunteers.

RESULTS

About 45% of volunteers scored high on performance. In the multivariate analysis, educational status [OR = 4.64 95% CI (1.22-17.45)] and ethnicity [OR = 1.85 95% CI (1.00-3.41)] were the factors that influenced the performance of health volunteers. Other intermediary factors such as incentives and means of transport also affected the performance of health volunteers engaged in health intervention activities at the community level.

CONCLUSION

The results suggest that higher educational status of health volunteers is more likely to increase their performance. In addition, providing non-monetary incentives and logistics such as bicycles, raincoats, torch lights and wellington boots will enhance the performance of health volunteers and also motivate them to continue to provide health services to their own people at the community level.