"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

A mixed methods study investigating factors affecting adherence to Plasmodium vivax malaria primaquine radical cure regimens among migrants along the Myanmar-Thailand border

BACKGROUND

The countries within the Greater Mekong Region of Southeast Asia have pledged to eliminate malaria by 2030. Elimination of Plasmodium vivax malaria is challenging as it requires radical cure to prevent relapse. Understanding and facilitating adherence to primaquine radical cure regimens is necessary for malaria elimination.

METHODS

A convergent parallel mixed methods study was conducted to investigate the barriers to and facilitators for completing primaquine treatment of P. vivax infection among mobile migrant communities on the Myanmar-Thailand border. Quantative data were derived from routine malaria consultations. Qualitative data, informed by the social cognitive theory and health belief model, were collected through in-depth interviews with patients and focus group discussions with local health providers and community leaders.

RESULTS

Of 729 adult patients with primaquine treatment outcomes, 45% did not complete the follow-up of 28 days and were assumed to be non-adherent to primaquine treatment. Patients of Karen ethnicity (OR 1.7, 95% CI 1.2-2.3; p = 0.001) or having a previous episode of malaria from any species (OR 1.6, 95% CI 1.1-2.3; p = 0.007) were more likely to report completing the 14-day primaquine radical cure regimen. Five focus group discussions with front-line healthcare workers and community members and 16 in-depth interviews with patients who were prescribed P. vivax radical cure were conducted. Key themes related to the social cognitive theory included behavioral factors where work outweighed the choice to complete treatment; environmental factors where access to care determined primaquine treatment completion; and cognitive factors having a positive but limited influence on treatment completion. According to the health belief model, prioritizaton of work reduced seeking diagnosis and completing treatment, and often outweighed facilitating factors such as malaria literacy, health education, and social norms; and affected the perceived susceptibility and severity of P. vivax infections.

DISCUSSION

Work and productivity were identified as primary behavioral factors affecting adherence to primaquine radical cure and follow up in a migrant population. Community support and cultural cues may overcome these barriers. Understanding the rationale of patient adherence to primaquine may help guide programming for P. vivax elimination among migrant populations in resource-constrained settings.

Community engagement to develop a dialogue-drama on adolescent pregnancy in a marginalised migrant population on the Thailand-Myanmar border: an ethnographic approach to participatory action research

BACKGROUND

Communities in which adolescent pregnancy and safe abortion care are taboo may benefit from culturally appropriate information, education, and communication.

OBJECTIVE

This ethnographic and participatory action research (PAR) elicited community members' perceptions to adolescent pregnancy: which then informed dialogue-drama development in Burmese and Karen language for undocumented migrants on the Thailand-Myanmar border.

METHODS

PAR was conducted in Karen and Burmese language. Interviews and discussions elicited perceptions of community members about adolescent pregnancy. These were analysed for themes and using the fishbone technique, to determine the objectives for the drama. After developing the structure and content of the drama it was piloted, revised, and performed in communities. Responses and impact of the drama were recorded. The team reflected on the drama as a method for health messaging.

RESULTS

In 2022, themes of responsibility, communication, and experiences of adolescent pregnancy emerged from 10 interviews and 6 discussions with community members. The fishbone technique established three dramatic objectives, woven into a teenage love story with an unplanned pregnancy, to raise community awareness of i) adolescent pregnancy, ii) contraception, and iii) choice in unexpected pregnancy. Post-drama feedback from 11 migrant communities (1,238 participants) was positive although some community members voiced concerns. Given the logistical challenges of conducting the drama in person, a film will be created for wider dissemination.

CONCLUSIONS

Participatory action research resulted in a culturally-nuanced performance, with communities requesting further performances and awareness on adolescent pregnancy and safe abortion care. Video is likely to be a more sustainable option.

Community engagement approaches for malaria prevention, control and elimination: a scoping review

INTRODUCTION

Globally malaria programmes have adopted approaches to community engagement (ACE) to design and deliver malaria interventions. This scoping review aimed to understand, map, and synthesise intervention activities guided by ACE and implemented by countries worldwide for the prevention, control and elimination of malaria.

METHODS

Three databases (Web of Science, Proquest, and Medline) were searched for peer-reviewed, primary studies, published in English between 1 January 2000 and 31 December 2022. Advanced Google was used to search for grey literature. The five levels of the International Association for Public Participation were used to categorise ACE - (1) Inform, (2) Consult, (3) involve, (4) Collaborate, and (5) Co-lead. Intervention activities were categorised as health education (HE), and/or health services (HS), and/or environmental management (EM). Outcomes were collected as knowledge, attitude, behaviour, help-seeking, health and HS and environment. Enablers and barriers were identified. Malaria intervention phases were categorised as (1) prevention (P), or (2) control (C), or (3) prevention and control (PC) or prevention, control and elimination (PCE).

RESULTS

Seventy-five studies were included in the review. Based on ACE levels, most studies were at the inform (n=37) and involve (n=26) level. HE (n=66) and HS (n=43) were the common intervention activities. HE informed communities about malaria, its prevention and vector control. EM activities were effective when complemented by HE. Community-based HS using locally recruited health workers was well-accepted by the community. Involvement of local leaders and collaboration with local stakeholders can be enablers for malaria intervention activities.

CONCLUSION

Involving local leaders and community groups in all stages of malaria prevention programmes is vital for successful interventions. Key elements of successful ACE, that is, consult, collaborate, and co-lead were under-represented in the literature and require attention. National programes must consult and collaborate with community stakeholders to develop ownership of the interventions and eventually co-lead them.

Community engagement in health systems interventions and research in conflict-affected countries: a scoping review of approaches

BACKGROUND

Healthcare research, planning, and delivery with minimal community engagement can result in financial wastage, failure to meet objectives, and frustration in the communities that programmes are designed to help. Engaging communities - individual service-users and user groups - in the planning, delivery, and assessment of healthcare initiatives from inception promotes transparency, accountability, and 'ownership'. Health systems affected by conflict must try to ensure that interventions engage communities and do not exacerbate existing problems. Engaging communities in interventions and research on conflict-affected health systems is essential to begin addressing effects on service delivery and access.

OBJECTIVE

This review aimed to identify and interrogate the literature on community engagement in health system interventions and research in conflict-affected settings.

METHODS

We conducted a scoping review using Arksey & O'Malley's framework, synthesising the data descriptively.

RESULTS

We included 19 of 2,355 potential sources identified. Each discussed at least one aspect of community engagement, predominantly participatory methods, in 12 conflict-affected countries. Major lessons included the importance of engaging community and religious leaders, as well as people of lower socioeconomic status, in both designing and delivering culturally acceptable healthcare; mobilising community members and involving them in programme delivery to increase acceptability; mediating between governments, armed groups and other organisations to increase the ability of healthcare providers to remain in post; giving community members spaces for feedback on healthcare provision, to provide communities with evidence that programmes and initiatives are working.

CONCLUSION

Community engagement in identifying and setting priorities, decision-making, implementing, and evaluating potential solutions helps people share their views and encourages a sense of ownership and increases the likely success of healthcare interventions. However, engaging communities can be particularly difficult in conflict-affected settings, where priorities may not be easy to identify, and many other factors, such as safety, power relations, and entrenched inequalities, must be considered.

Outdoor residual spraying for malaria vector-control in Kayin (Karen) state, Myanmar: A cluster randomized controlled trial

Outdoor and early biting by mosquitoes challenge the efficacy of bed nets and indoor residual spraying against malaria in the Greater Mekong Subregion. The objective of this study was to assess the efficacy of outdoor residual spraying (ORS) for malaria vector-control in this region. A cluster randomized controlled trial was conducted between July 2018 and April 2019 in twelve villages in Karen (Kayin) state, Myanmar. Villages were randomly assigned to receive either a single round of ORS with a capsule suspension of lambda-cyhalothrin for two days in October or no intervention (six villages per group). The primary endpoint was the biting rate of malaria mosquitoes assessed with human-landing catch and cow-baited trap collection methods, and was analyzed with a Bayesian multi-level model. In the intervention villages, the proportion of households located within the sprayed area ranged between 42 and 100% and the application rate ranged between 63 and 559 g of active ingredient per hectare. At baseline, the median of Anopheles biting rate estimates in the twelve villages was 2 bites per person per night (inter-quartile range [IQR] 0–5, range 0–48) indoors, 6 bites per person per night (IQR 2–16, range 0–342) outdoors and 206 bites per cow per night (IQR 83–380, range 19–1149) in the cow-baited trap. In intention-to-treat analysis, it was estimated that ORS reduced biting rate by 72% (95% confidence interval [CI] 63–79) from Month 0 to Month 3 and by 79% (95% CI 62–88) from Month 4 to Month 6, considering control villages as the reference. In conclusion, ORS rapidly reduces the biting rates of malaria mosquitoes in a Southeast Asian setting where the vectors bite mostly outdoors and at a time when people are not protected by mosquito bed nets.

Cross-border strategies for access to healthcare in violent conflict - A scoping review

Background

The geographical reconfiguration of healthcare systems in times of violent conflict is increasingly being recognised in academic literature. This includes conflict-induced, cross-border travel for medical treatment. Yet the conceptual approach to this healthcare-seeking behaviour, by a population here referred to as cross-border population, remains poorly understood. This scoping review identifies academic literature on cross-border populations to map the current approach to cross-border populations and to propose a research agenda.

Methods

The study used a scoping review following the Joanna Briggs Institute Scoping Review methodology. We included articles on conflicts between 1980 and 2019.

Results

A total of 53 articles met the inclusion criteria. From these articles, we distinguished four types of studies on cross-border healthcare: Direct analysis, implicit analysis, clinical research, and identification. The 45 articles belonging to the first three categories were then searched for themes specifically relevant to healthcare for cross-border populations and linked with sub-themes such as border crossing time and the types of healthcare available. These themes were structured into three main areas: access to care; quality of care; and governance of care. Our analysis then describes the available knowledge, documented practices, and challenges of cross-border healthcare specifically in conflict settings.

Conclusions

A better understanding of cross-border healthcare systems is required to inform local practices and develop related regional and international policies. While the reviewed literature provides some highlights on various practices of cross-border healthcare, there are many gaps in available knowledge of this topic. To address these gaps, our study proposes a research framework outlining key themes and research questions to be investigated by signposting where major research and operational gaps remain. This facilitates well-directed future work on cross-border therapeutic geographies in the context of armed conflict and furthers understanding of a hitherto largely ignored area of the international healthcare system.

Community engagement for malaria elimination in the Greater Mekong Sub-region: a qualitative study among malaria researchers and policymakers

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.

Incorporating qualitative research methods into the monitoring and evaluation of neglected tropical disease programmes: a scoping literature review

This publication addresses the limited use of qualitative methods in neglected tropical disease (NTD) programmes. It describes a scoping literature review conducted to inform the development of a guide to inform the use of rapid qualitative assessments to strengthen NTD mass drug administration (MDA) programmes. The review assessed how qualitative methods are currently used by NTD programmes and identified qualitative approaches from other health and development programmes with the potential to strengthen the design of MDA interventions. Systematic review articles were reviewed and searched using key terms conducted on Google Scholar and PubMed. Results show that methods used by NTD programmes rely heavily on focus group discussions and in-depth interviews, often with time-consuming analysis and limited information on how results are applied. Results from other fields offered insight into a wider range of methods, including participatory approaches, and on how to increase programmatic uptake of findings. Recommendations on how to apply these findings to NTD control are made. The topic of human resources for qualitative investigations is explored and a guide to improve MDAs using qualitative methods is introduced. This guide has direct applicability across the spectrum of NTDs as well as other public health programmes.

Acceptability and feasibility of malaria prophylaxis for forest goers: findings from a qualitative study in Cambodia

BACKGROUND

In the Greater Mekong Subregion, adults are at highest risk for malaria, particularly those who visit forests. The absence of effective vector control strategies and limited periods of exposure during forest visits suggest that chemoprophylaxis could be an appropriate strategy to protect forest goers against malaria.

METHODS

Alongside a clinical trial of anti-malarial chemoprophylaxis in northern Cambodia, qualitative research was conducted, including in-depth interviews and observation, to explore the acceptability of malaria prophylaxis for forest goers, the implementation opportunities, and challenges of this strategy.

RESULTS

Prophylaxis with artemether-lumefantrine for forest goers was found to be acceptable under trial conditions. Three factors played a major role: the community's awareness and perception of the effectiveness of prophylaxis, their trust in the provider, and malaria as a local health concern. The findings highlight how uptake and adherence to prophylaxis are influenced by the perceived balance between benefits and burden of anti-malarials which are modulated by the seasonality of forest visits and its influence on malaria risk.

CONCLUSIONS

The implementation of anti-malarial prophylaxis needs to consider how the preventive medication can be incorporated into existing vector-control measures, malaria testing and treatment services. The next step in the roll out of anti-malarial prophylaxis for forest visitors will require support from local health workers.

End-user perspectives on preventive antimalarials: A review of qualitative research

Antimalarials have been administered widely to prevent clinical malaria and researchers have explored how end-users' perspectives influence uptake and adherence. Drawing on a systematic search, this review aims to synthesise qualitative research on end-user perceptions of antimalarials for disease prevention. Searches were undertaken in PubMed and ISI Web of Knowledge. After applying exclusion criteria, identified sources underwent thematic analysis. Identified sources were published between 2000 and 2020 and drew on studies undertaken across Africa, Asia, Europe, Oceania and America. The sources revealed end-user concerns about the potential benefits and harms of preventive treatment that are entwined with broader understandings of the disease, the intervention, its implementation, accompanying information, and how it is embedded in wider healthcare and social relationships. The implications for antimalarials as preventive therapy encompass the need to build trust, including interpersonal trust, engage diverse stakeholders and to address broader health and wellbeing concerns during implementation.

Community engagement and ethical global health research

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