Evaluation of a school-based HIV/AIDS peer-led prevention programme: the first intervention trial for children of migrant workers in China

Factors associated with access to HIV testing among international students in Japanese language schools in Tokyo

Japan has been recognized for its excellent universal health coverage system. However, the migrant population faces many barriers in accessing health services in Japan. Japan hosts around 260,000 international students, mostly from developing countries. Among them, language school students tripled from 2011 to 2017, against the backdrop of labor shortage in Japan. Most of these students are also engaged as cheap laborers and are vulnerable populations with poor access to health services. Several socio-economic and behavioral factors may increase their vulnerability to HIV and prevent them from accessing HIV testing in Japan. We examined the factors associated with access to HIV testing among international students in language schools in Tokyo. We conducted a cross-sectional study among international students studying in Japanese language schools in Tokyo. We collected data from 769 Chinese, Vietnamese, and Nepalese students using a self-administered questionnaire. We measured their access to HIV testing through questions on their knowledge of where to receive HIV testing and utilization of HIV testing. Bivariate and multivariable logistic regression models were used to analyze the data. Nepalese students were less likely to know where to receive HIV testing in Japan than Chinese students (AOR = 0.12, 95% CI 0.01–0.96). Students who did not need Japanese language interpreters during visits to health facilities were more likely to know where to receive HIV testing (AOR = 1.93, 95% CI 1.14–3.25). Students who did not have knowledge of free and anonymous HIV testing in Japan were also less likely to know where to receive HIV testing in Japan (AOR = 0.18, 95% CI 0.08–0.42). Students who did not have knowledge of free and anonymous HIV testing (OR = 0.05, 95% CI 0.02–0.10) and who had not utilized HIV testing in their home country (OR = 0.12, 95% CI 0.06–0.27) were less likely to utilize HIV testing in Japan. Factors associated with access to HIV testing among Japanese language school students in Tokyo are nationality, need for Japanese language interpreters, perceived access to doctors/health workers, utilization of HIV testing in the home country, and knowledge of free and anonymous HIV testing. These findings may help to design interventions for improving access to HIV testing among international students in Japan.

Epidemiological characteristics of HIV infection among college students in Nanjing, China: a cross-sectional survey

OBJECTIVE

This study aimed to investigate the epidemiological characteristics and HIV/AIDS-related knowledge, attitudes and practice (KAP) among HIV-positive college students.

DESIGN

A cross-sectional study.

SETTING

Five districts of Nanjing, China.

PARTICIPANTS

A total of 156 college students with newly diagnosed HIV infection between September 2015 and July 2017.

MAIN OUTCOME MEASURES

Social-demographic characteristics, mode of HIV acquisition, infection of sexually transmitted diseases, risky sexual behaviours and HIV/AIDS-related KAP were collected by a face-to-face questionnaire administered by trained interviewers.

RESULTS

About 98.7% (154/156) of HIV-positive college students in our study were men, and 96.1% (148/154) of them were infected by sexual intercourse with men. More than half (52.5%, 82/156) of participants were freshmen or sophomores. Nearly 30% (44/154) of male students did not realise the severe status of the HIV/AIDS epidemic among students who are men who have sex with men (MSM). More than four-fifths of male students did not know if their male regular (83.0%, 93/112) or casual (95.9%, 94/98) sexual partners were HIV-positive, while less than half of them had high-risk perceptions towards HIV infection from male regular and occasional sexual partners. Approximately one-half and four-fifths of male students had more than two regular (54.5%, 61/112) and occasional (79.6%, 78/98) partners during lifetime, respectively. However, only 62.5% (70/112) and 66.3% (65/98) of male students used condoms consistently during sexual intercourse with regular and casual partners, respectively. Geosocial networking apps have become the most dominant way for male students to seek sexual partners.

CONCLUSIONS

This study reported a low level of HIV/AIDS-related knowledge, a high level of exposure to risky sexual behaviours and some valuable epidemiological characteristics among HIV-positive college students, which highlighted the importance of carrying out HIV/AIDS prevention education and risk warning education early and timely towards college students on campus.

Interventions to improve the HIV continuum of care in China

PURPOSE OF REVIEW

To describe HIV epidemic and interventions for improving HIV continuum of care in China.

RECENT FINDINGS

The reported HIV epidemic has been continuously increasing, partially due to the expansion of active HIV testing campaign. Public health intervention programs have been effective in containing HIV spread among former plasma donors and people who inject drugs (PWID), but more infections occur among heterosexual men and women and young men who have sex with men. Of 1.25 million Chinese people are living with HIV, one-third do not know their status. About two-thirds of diagnosed individuals have used antiretroviral therapy (ART) and two-thirds of those on ART have achieved viral suppression, but some risk groups such as PWID have lower rates. The national free ART program has reduced adult and pediatric mortality and reduced heterosexual transmission. China faces great challenges to reduce HIV sexual transmission, improve the HIV continuum of care, and close the gaps to the UNAIDS Three "90" Targets.

Positive Youth Development Programs in Low- and Middle-Income Countries: A Conceptual Framework and Systematic Review of Efficacy

PURPOSE

Positive youth development (PYD) has served as a framework for youth programs in high-income countries since the 1990s and has demonstrated broad behavioral health and developmental benefits. PYD programs build skills, assets, and competencies; foster youth agency; build healthy relationships; strengthen the environment; and transform systems to prepare youth for successful adulthood. The goal of this article was to systematically review the impact of PYD programs in low- and middle-income countries (LMICs).

METHODS

Targeted searches of knowledge repository Web sites and keyword searches of Scopus and PubMed identified over 21,500 articles and over 3,700 evaluation reports published between 1990 and mid-2016. Ninety-four PYD programs with evaluations in LMICs were identified, of which 35 had at least one experimental or rigorous quasi-experimental evaluation.

RESULTS

Sixty percent of the 35 programs with rigorous evaluations demonstrated positive effects on behaviors, including substance use and risky sexual activity, and/or more distal developmental outcomes, such as employment and health indicators.

CONCLUSIONS

There is promising evidence that PYD programs can be effective in LMICs; however, more rigorous examination with long-term follow-up is required to establish if these programs offer benefits similar to those seen in higher income countries.

Assessing Participation and Effectiveness of the Peer-Led Approach in Youth Sexual Health Education: Systematic Review and Meta-Analysis in More Developed Countries

Sexual health education for young people is crucial not only for development of norms but also for protection against vulnerabilities during this stage in life. Although several systematic reviews have examined the effectiveness of peer-led sex education, none have focused on the extent of peer participation. The purpose of this review was to evaluate peer-led sexual health education interventions in more developed countries (MDCs). Electronic and manual searches across five social science, education, and medical databases were conducted. Fifteen articles were selected in total. Most (10 of 15) studies gave low or no responsibility to peers. The majority of articles found improvements in sexual health knowledge (13 of 14) and attitudes (11 of 15) at postintervention stages. Two studies showed improved self-efficacy, and three showed behavioral changes. A preliminary synthesis of effectiveness and level of participation was done. Meta-analysis revealed a large effect on knowledge change (Hedges' g = 0.84, 95% confidence interval [CI]: 0.43 to 1.25) and a medium effect on attitude change (Hedges' g = 0.49, 95% CI: 0.19 to 0.80). Peer-led interventions could be a powerful tool. This review shows that this approach is effective in changing knowledge and attitudes but not behaviors. Further research and action are needed to understand optimal implementation.

School based sex education and HIV prevention in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

School-based sex education is a cornerstone of HIV prevention for adolescents who continue to bear a disproportionally high HIV burden globally. We systematically reviewed and meta-analyzed the existing evidence for school-based sex education interventions in low- and middle-income countries to determine the efficacy of these interventions in changing HIV-related knowledge and risk behaviors.

METHODS

We searched five electronic databases, PubMed, Embase, PsycInfo, CINAHL, and Sociological Abstracts, for eligible articles. We also conducted hand-searching of key journals and secondary reference searching of included articles to identify potential studies. Intervention effects were synthesized through random effects meta-analysis for five outcomes: HIV knowledge, self-efficacy, sexual debut, condom use, and number of sexual partners.

RESULTS

Of 6191 unique citations initially identified, 64 studies in 63 articles were included in the review. Nine interventions either focused exclusively on abstinence (abstinence-only) or emphasized abstinence (abstinence-plus), whereas the remaining 55 interventions provided comprehensive sex education. Thirty-three studies were able to be meta-analyzed across five HIV-related outcomes. Results from meta-analysis demonstrate that school-based sex education is an effective strategy for reducing HIV-related risk. Students who received school-based sex education interventions had significantly greater HIV knowledge (Hedges g = 0.63, 95% Confidence Interval (CI): 0.49-0.78, p<0.001), self-efficacy related to refusing sex or condom use (Hedges g = 0.25, 95% CI: 0.14-0.36, p<0.001), condom use (OR = 1.34, 95% CI: 1.18-1.52, p<0.001), fewer sexual partners (OR = 0.75, 95% CI:0.67-0.84, p<0.001) and less initiation of first sex during follow-up (OR = 0.66, 95% CI: 0.54-0.83, p<0.001).

CONCLUSIONS

The paucity of abstinence-only or abstinence-plus interventions identified during the review made comparisons between the predominant comprehensive and less common abstinence-focused programs difficult. Comprehensive school-based sex education interventions adapted from effective programs and those involving a range of school-based and community-based components had the largest impact on changing HIV-related behaviors.

Beyond the clinic walls: empowering young people through Youth Peer Provider programmes in Ecuador and Nicaragua

Youth in Latin America experience high rates of teen pregnancy and sexually transmitted infections, but traditional health services are not meeting their health care needs. Youth require access to tailored health care and information to make informed, healthy decisions. To break down barriers to these vital sexual and reproductive health services, Planned Parenthood Global, a division of Planned Parenthood Federation of America, developed a Youth Peer Provider model which has been implemented in Latin America since the early 1990s. The model goes beyond peer education to train Youth Peer Providers under age 20 to provide condoms, oral contraceptive pills, emergency contraception, injectable contraceptives, and sexual and reproductive health information to their peers. Peers with needs beyond Youth Peer Providers' capacity are referred to health professionals offering youth-friendly services. Survey results reveal high levels of contraceptive use among those served by the Youth Peer Providers: 98% of sexually active survey respondents wishing to avoid pregnancy report contraceptive use at least five years after joining the programme. Results of qualitative programme evaluations highlight higher self-esteem, stronger communication and decision-making skills, close relationships with friends and family, more interest in school, understanding of responsibility in relationships, and other positive outcomes among programme participants.

Advancing the prevention agenda for HIV and other sexually transmitted infections in south China: social science research to inform effective public health interventions

Despite widespread biomedical advances in treatment and prevention, HIV and other sexually transmitted infections (STI) continue to affect a large portion of the world's population. The profoundly social nature of behaviorally driven epidemics and disparities across socioeconomic divides in the distribution of HIV/STI and care outcomes emphasize the need for innovative, multilevel interventions. Interdisciplinary approaches to HIV/STI control are needed to combine insights from the social and biological sciences and public health fields. In this concluding essay to a Special Issue on HIV/STI in south China, we describe the evolution of the region's HIV/STI epidemics and the government response, then synthesize findings from the 11 studies presented in this issue to extend seven recommendations for future HIV/STI prevention and care research in China. We discuss lessons learned from forging international collaborations between the social and biological sciences and public health to inform a shared research agenda to better meet the needs of those most affected by HIV and other STI.

Labor migration, externalities and ethics: theorizing the meso-level determinants of HIV vulnerability

This paper discusses labor migration as an example of how focusing on the meso-level highlights the social processes through which structural factors produce HIV risk. Situating that argument in relation to existing work on economic organization and HIV risk as well as research on labor migration and HIV vulnerabilities, the paper demonstrates how analyzing the processes through which labor migration creates vulnerability can shift attention away from the proximate behavioral determinants of HIV risk and toward the community and policy levels. Further, it presents the concepts of externalities and the ethics of consumption, which underline how both producers and consumers benefit from low-waged migrant labor, and thus are responsible for the externalization of HIV risk characteristic of supply chains that rely on migrant labor. These concepts point to strategies through which researchers and advocates could press the public and private sectors to improve the conditions in which migrants live and work, with implications for HIV as well as other health outcomes.

The study of KBP of road construction workers of highway AIDS prevention project before and after intervention

OBJECTIVE

To get scientific basis for further health education through the research of the road construction workers' KBP before and after the interventions of highway AIDS prevention project.

METHODS

Multi-stage random sampling method was employeed to select workers of 8 sites from 14 sites along highway to investigate their AIDS knowledge, belief and performance (KBP) before and after highway AIDS prevention project.

RESULTS

Over 90% of the investigated workers had ever heard about AIDS, and the non-skilled workers of lower educational level improved more after intervention. The correct answer rate of the three transmitting ways of AIDS of drivers which is the focused group of highway before and after intervention had the obvious statistical significance (P<0.05), and the other group's correct answer rates also had improved after intervention. Most people's understanding of preventing AIDS through correct use of condoms when having sex had a statistically significant difference(P<0.05) after prevention. The rates of using condoms of foremen and skilled workers when having sex with commercial sex worker/casual partner increased after intervention.

CONCLUSIONS

The health education of HIV among the road construction workers is effective and further health education of HIV prevention should be carried out among the road construction workers to improve their knowledge and awareness of avoiding the high-risk behaviors.

Systematic review of HIV prevention interventions in China: a health communication perspective

OBJECTIVES

To examine whether communication strategies and principles have been utilized in the HIV prevention intervention programs conducted in China.

METHODS

Comprehensive literature searches were conducted using PsycINFO, Medline, and Academic Search Complete with combinations of a number of keywords. Studies were included if they (1) were conducted in China and published prior to October 2011; (2) tested interventions promoting HIV/sexual risk reduction; and (3) reported empirical outcome evaluations on HIV knowledge, condom use and other condom-related variables. Data on 11 dimensions were extracted and analyzed, including formative research, theory, message targeting, messenger and channels, process evaluation, evaluation design, outcome measures.

RESULTS

The majority of the 45 intervention studies were not theory-based, did not report conducting formative research or process evaluation, used pretest-posttest control group designs, combined nonmedia channels, printed and visual materials, and employed HIV knowledge and condom use as outcome measures.

CONCLUSIONS

Many HIV prevention interventions in China have been successful in reducing HIV risk-related outcomes. This literature has its weaknesses; however, the current review illuminates gaps in the literature and points to important future directions for research.

HIV/sexual risk reduction interventions in China: a meta-analysis

The current study was a meta-analysis of the efficacy of educational, psychosocial or behavioral interventions that were conducted in China to promote HIV/sexual risk reduction. A total of 26 intervention studies qualified for the meta-analysis. Outcome variables for which effect sizes were calculated included condom use with different types of sexual partners, HIV/AIDS knowledge, condom use knowledge, intentions of condom use, condom use self-efficacy, and others. Mean weighted effect sizes were calculated for each outcome measure across reviewed studies; effect size for each outcome measure was weighted by their inverse variance; fixed effects and random effects meta-analytic procedures were used. The Q statistic was used to examine whether the effect sizes were homogeneous in nature and moderating analysis (i.e., the Q(b) statistic) was used to compare the effect sizes of intervention studies that were different in a number of categorical variables. The reviewed interventions were successful in improving HIV knowledge (d=0.706), condom use knowledge (d=0.620), attitudes toward people living with HIV/AIDS (PLWHA; d=0.625) and in increasing condom use with regular partners (d=0.477), condom use with casual partners (d=0.444), general condom use (d=0.408), and condom use self-efficacy (d=0.584) among target audiences. In addition, moderating analyses on three most examined variables, including HIV knowledge, condom use, and attitudes toward PLWHA, demonstrated that interventions that reported the conduction of formative research and process evaluation, that were peer-led, and that included only one follow-up were more likely to report a positive impact on condom use behavior among target audiences (p<0.001), HIV knowledge (p<0.001), or attitudes toward PLWHA (p<0.001).

Effect of social influences on pharmacists' intention to report adverse drug events

OBJECTIVES

To identify the groups or individuals that influence pharmacists' decision making to report adverse drug events (ADEs), determine the differences in social influence or subjective norm between intenders and nonintenders, and determine the relationship between subjective norm toward reporting serious ADEs and practice and demographic characteristics.

DESIGN

Nonexperimental cross-sectional study.

SETTING

Texas during June and July 2009.

PARTICIPANTS

1,500 Texas pharmacists.

INTERVENTION

As part of a larger survey, 3 and 18 items were used to assess pharmacists' intentions and subjective norm, respectively, to report serious ADEs to the Food and Drug Administration (FDA).

MAIN OUTCOME MEASURE

Pharmacists' subjective norm toward reporting serious ADEs.

RESULTS

The survey had a response rate of 26.4% (n = 377). Most pharmacists intended to report serious ADEs that they would encounter (15.87 ± 4.22 [mean ± SD], possible range 3-21, neutral = 12). The mean subjective norm scores were moderately high and positive (28.75 ± 9.38, 1-49, 16), indicating that the referents had a moderate influence on pharmacists regarding reporting serious ADEs to FDA. FDA had the greatest (34.82 ± 12.16) and drug manufacturers the lowest (21.55 ± 13.83) social influence. The most important salient referents (important others) in pharmacists' decisions to report serious ADEs were FDA, patients, pharmacy associations, pharmacy managers/bosses, and hospitals and hospital groups. Gender (female equals higher), pharmacists' years of experience (negative correlation), and knowledge of ADE reporting (positive correlation) were associated with subjective norm.

CONCLUSION

Pharmacists had a moderately high subjective norm, suggesting that ADE reporting intentions is influenced by others and that the opinions of others are of great importance in pharmacists' intentions regarding ADE reporting. The main drivers of subjective norm were FDA, patients, pharmacy associations, and managers/bosses.

Labor migration and HIV risk: a systematic review of the literature

To inform the development of multilevel strategies for addressing HIV risk among labor migrants, 97 articles from the health and social science literatures were systematically reviewed. The study locations were Africa (23 %), the Americas (26 %), Europe (7 %), South East Asia (21 %), and Western Pacific (24 %). Among the studies meeting inclusion criteria, HIV risk was associated with multilevel determinants at the levels of policy, sociocultural context, health and mental health, and sexual practices. The policy determinants most often associated with HIV risk were: prolonged and/or frequent absence, financial status, and difficult working and housing conditions. The sociocultural context determinants most often associated with HIV risk were: cultural norms, family separation, and low social support. The health and mental health factors most often associated with HIV risk were: substance use, other STIs, mental health problems, no HIV testing, and needle use. The sexual practices most often associated with increased HIV risk were: limited condom use, multiple partnering, clients of sex workers, low HIV knowledge, and low perceived HIV risk. Magnitude of effects through multivariate statistics were demonstrated more for health and mental health and sexual practices, than for policy or sociocultural context. The consistency of these findings across multiple diverse global labor migration sites underlines the need for multilevel intervention strategies. However, to better inform the development, implementation, and evaluation of multilevel interventions, additional research is needed that overcomes prior methodological limitations and focuses on building new contextually tailored interventions and policies.

Tracking the evolution of HIV/AIDS in China from 1989-2009 to inform future prevention and control efforts

Background

To determine policy implications, this analysis tracks the evolution of HIV/AIDS infection across China to understand current trends and potential risk factors.

Methods and Principal Findings

A retrospective study with spatial analytical model and multilevel spatial models was conducted among 326,157 HIV/AIDS cases reported from 1989–2009. The results indicate that the distribution of HIV/AIDS was clustered at the county level with different directional distributions across China from 2003 to 2009. Compared to 2003, by 2009 there was a 122% increase in HIV cases among rural residents, 294% increase among urban residents, 211% increase among migrants, and 237% increase among permanent residents. The overall proportion of HIV by different routes of transmission showed dramatic changes with a 504% increase in sexual transmission of HIV, 90% decrease in blood/plasma transmission, and 35% decrease in injecting drug user transmission. Sexual transmission was the major transmission route among women (44%) and the elderly (59% in men, 44% in women) as well as among permanent (36%) and urban residents (33%). Among those <65 years old, women increased more than men, but among those ≥65 years, men increased more than women. Migrants contributed to the variance of HIV infection between counties but not within counties. The length of highway and urbanization combined with illiteracy were risk factors for HIV/AIDS.

Conclusions/Significance

Rates of HIV/AIDS among permanent urban residents, particularly women and elderly men, have increased significantly in recent years. To prevent HIV from spreading further among the general population, additional attention should be paid to these populations as well as to migrants.

AIDS knowledge and HIV stigma among children affected by HIV/AIDS in rural China

The current study was designed to assess the level of AIDS knowledge and its relationship with personal stigma toward people living with HIV/AIDS (PLWHA) among children living in communities of high HIV prevalence in rural China. The data were collected in 2009 from 118 orphanage orphans (children who had lost both of their parents to HIV and living in AIDS orphanages), 299 family-cared orphans (children who had lost one or both of their parents to HIV and living with surviving parents or extended families), 326 vulnerable children (children who were living with HIV-infected alive parents), and 276 comparison children (children from the same community who did not experience HIV-related illness and death in their family). Children were asked to answer 20 questions of AIDS knowledge. A 10-item stigma scale was employed to assess children's own attitude toward PLWHA. Both bivariate and multivariate tests were performed to answer our research questions. The data in the current study demonstrate a relatively low percent of correct AIDS knowledge (60%) among samples. The comparison children reported the best score of AIDS knowledge and orphanage orphans scored the lowest. The children with better AIDS knowledge have less personal stigma toward PLWHA. The findings in the current study suggest the need of appropriate education strategies to provide AIDS knowledge to children, particularly for HIV-affected children living in communities of high HIV prevalence in rural China.

Evaluation of a school-based HIV prevention intervention among Yemeni adolescents

Background

This article describes an evaluation of a school-based peer education intervention for HIV prevention among students in twenty seven high schools in Aden, Yemen. The intervention was developed after a survey among the same population in 2005, which revealed a high level of stigma towards people living with HIV (PLWH) and a low level of HIV knowledge.

Methods

In a quasi-experimental design students who received the peer education intervention (78.6%) were compared with students who did not receive the intervention (21.4%). No systematic procedure was applied in selecting students for the intervention condition. Data were collected using a self-administered questionnaire from a sample of 2510 students from all 27 high-schools in Aden governorate. To increase internal validity, students were also compared with a cohort control sample surveyed in 2005, which was a random sample of 2274 students from the same schools.

Results

Sixty eight percent of students targeted by peer education had good knowledge scores, compared with 43.3% of students not targeted by peer education (χ² = (df = 1) = 111.15, p < .01). Multi-level regression analysis revealed that, although there was a significant difference among schools, the intervention effect of peer education at the individual level was significant; students who received peer education had a statistically higher knowledge score(9.24 out of 12.0) compared with those not targeted (7.89 out of 12.0), OR = 2.11, 95% CI = 1.04-4.27, p < .05). Compared with the 2005 cohort control sample, students targeted by peer education had better knowledge on the modes of transmission and prevention and fewer misconceptions; and knowledge on the use of condoms increased from 49.4% to 67.8%. In addition, students who received the peer education interventions suggested significantly more actions to provide care and support for PLWH. Also, the levels of stigma and discrimination were much higher among the 2005 cohort control group, compared with those who received the peer education intervention.

Conclusion

The school-based peer education intervention has succeeded in improving levels of knowledge on modes of transmission and prevention, and in decreasing levels of stigma and discrimination in a culturally conservative setting.

Community participation for malaria elimination in Tafea Province, Vanuatu: Part I. Maintaining motivation for prevention practices in the context of disappearing disease

Background

In the 1990s, the experience of eliminating malaria from Aneityum Island, Vanuatu is often given as evidence for the potential to eliminate malaria in the south-west Pacific. This experience, however, cannot provide a blueprint for larger islands that represent more complex social and environmental contexts. Community support was a key contributor to success in Aneityum. In the context of disappearing disease, obtaining and maintaining community participation in strategies to eliminate malaria in the rest of Tafea Province, Vanuatu will be significantly more challenging.

Method

Nine focus group discussions (FGDs), 12 key informant interviews (KIIs), three transect walks and seven participatory workshops were carried out in three villages across Tanna Island to investigate community perceptions and practices relating to malaria prevention (particularly relating to bed nets); influences on these practices including how malaria is contextualized within community health and disease priorities; and effective avenues for channelling health information.

Results

The primary protection method identified by participants was the use of bed nets, however, the frequency and motivation for their use differed between study villages on the basis of the perceived presence of malaria. Village, household and personal cleanliness were identified by participants as important for protection against malaria. Barriers and influences on bed net use included cultural beliefs and practices, travel, gender roles, seasonality of mosquito nuisance and risk perception. Health care workers and church leaders were reported to have greatest influence on malaria prevention practices. Participants preferred receiving health information through visiting community health promotion teams, health workers, church leaders and village chiefs.

Conclusion

In low malaria transmission settings, a package for augmenting social capital and sustaining community participation for elimination will be essential and includes: 'sentinel sites' for qualitative monitoring of evolving local socio-cultural, behavioural and practical issues that impact malaria prevention and treatment; mobilizing social networks; intersectoral collaboration; integration of malaria interventions with activities addressing other community health and disease priorities; and targeted implementation of locally appropriate, multi-level, media campaigns that sustain motivation for community participation in malaria elimination.