In search of the last malaria cases: ethnographic methods for community and private-sector engagement in malaria elimination in Vietnam, Laos, and Cambodia

Social determinants of malaria in low- and middle-income countries: a mixed-methods systematic review

BACKGROUND

Malaria remains a leading cause of morbidity and mortality in many low- and middle-income countries (LMICs). Factors outside the health sector, including social determinants, such as economic status remain important drivers of malaria in these settings. However, social determinants of malaria generally remain unaddressed in preventing the disease, with the limited existing evidence overly descriptive and fragmented.

METHODS

A mixed-methods systematic review was conducted to thematically synthesize the current evidence on the social determinants of malaria in LMICs. PubMed, Web of Science, and Scopus were searched to identify English articles on the social determinants of malaria published between January 2013 and December 2023. Search terms such as social determinant, socio-cultural, and socioeconomic factors were used. Articles that did not meaningfully engage with the social determinants were excluded.

RESULTS

The 39 articles included in the review were mostly cross-sectional and qualitative studies of moderate quality, in general. Findings indicate a range of social determinants of malaria related to the following overarching themes: environmental factors, access to and use of treatment, preventive interventions use, housing, stakeholder influence, livelihoods and economic development, and poverty. The various social determinants influenced malaria in different ways, including limiting access and use of preventive and treatment interventions and increased exposure to mosquitoes. Poverty and gender intersected with other social determinants such as housing and livelihoods.

CONCLUSION

Different social determinants of malaria are key drivers of malaria in LMICs. The findings emphasize the need for malaria control efforts to consider social determinants at all levels, including funding, implementation, and evaluation.

Willingness to pay for a mosquito bite prevention 'forest pack' in Cambodia: results of a discrete choice experiment

BACKGROUND

Progress towards malaria elimination in the Greater Mekong Subregion has left much of the residual malaria transmission concentrated among forest-exposed populations for whom traditional domicile focused malaria vector control is unlikely to be effective. New tools to protect these populations from vector biting outdoors are needed.

METHODS

Alongside implementation research on the deployment of a "forest pack" consisting of a volatile pyrethroid (transfluthrin)-based spatial repellent (VPSR), a picaridin-based topical repellent and etofenprox treatment of clothing, an assessment was made of participant willingness to pay for the forest packs and variants of the packs using a discrete choice experiment.

RESULTS

Participants showed willingness to pay for forest packs consistent with full-cost recovery for VPSR devices. The inclusion of a full malaria season's worth of VPSR devices increased the willingness to pay for a forest pack by 15% (p = 0.061). At a price of approximately 10 USD, approximately 50% of participants were willing to pay for a forest pack which included a full season's worth of VPSR.

CONCLUSION

Forest packs which include VPSR are likely to be acceptable to the target forest-exposed populations, and those which include VPSR products may even have potential for commercial sales or some cost-recovery.

Forest-Going as a Risk Factor for Confirmed Malaria in Champasak Province, Lao PDR: A Case-Control Study

Lao People's Democratic Republic (Lao PDR) has made significant progress in reducing malaria in recent years. In the Greater Mekong Subregion, forest-going is often a risk factor contributing to continuing malaria transmission. This study assessed forest-going and other potential risk factors for malaria cases in Champasak Province, Lao PDR. Routine passive surveillance data from August 2017 to December 2018 were extracted from health facilities in three districts for a case-control study; at the time of presentation, all fever cases were asked to report any recent forest travel. Multivariable logistic regression was used to assess the relationship between forest-going and malaria infection while controlling for other covariates. Of 2933 fever cases with data available on forest-sleeping and malaria diagnosis from 25 health facilities, 244 (8%) tested positive (cases), and 2689 (92%) tested negative (controls). Compared with spending 0-2 nights in the forest, spending 3-7 nights in the forest was associated with 9.7 times the odds of having a malaria infection (95% CI: 4.67-20.31, p < 0.001) when adjusting for gender, occupation, and season. Forest-going, especially longer trips, is associated with increased risk for confirmed symptomatic malaria in southern Lao PDR, and appropriate and targeted intervention efforts are needed to protect this high-risk population.

Expanded roles of community health workers beyond malaria in the Asia-Pacific: A systematic review

In the Greater Mekong Subregion (GMS), community health workers (CHWs) are a key component of malaria elimination strategies. As malaria declines, support for, and uptake of, malaria services may also subsequently decrease. Expanding their roles beyond malaria has been proposed to sustain the services. A systematic review was conducted to identify and characterize programmes with CHWs providing services in addition to those for malaria in the Asia Pacific. This review describes the expanded roles, identifies evidence of impact or success of the programmes, and explores strategies to ensure sustainability and factors for effective implementation to inform the design of malaria CHW programmes. Searches were conducted in 6 databases, for grey literature, and in bibliographies of retrieved articles. Data were extracted from 38 published articles, 12 programme reports, and 4 programme briefs and analysed using thematic coding and descriptive analysis. Twenty-nine programmes were identified with CHWs performing both malaria and non-malaria roles in the Asia Pacific. There was evidence of impact on malaria incidence in 4 of these, none on malaria mortality, and 4 on other diseases. Monitoring and evaluation mechanisms, multi-sectoral stakeholder collaborations, and adequate training and consistent supervision of CHWs were key to effective programme implementation. Integration of programmes into broader health services, ongoing political and funding support, and engagement with local communities were found to contribute to sustaining provision of health services by CHWs. Expanding CHW roles depends on programme management and strengthening linkages with local health systems. To sustain malaria CHW services, countries need adequate policies and financing, and sufficiently strong health systems to deliver basic health services that are adapted to the health needs of the community which means transitioning away from vertical disease programs. Further research should explore programmes that have not been captured in this review and address gaps in measuring malaria outcomes.

Core principles of Malakit intervention for transferability in other contexts

To eliminate malaria, all populations must be included. For those who are not reached by the health care system, specific interventions must be tailor-made. An innovative Malakit strategy, based on the distribution of self-diagnosis and self-treatment kits, has been evaluated in the Suriname-French Guiana- Amapá (Brazil) region. The results showed effectiveness and good acceptability. The Malakit intervention is complex and has many components. Its transferability requires adaptation to other populations and regions, while retaining the main features of the intervention. This article provides the keys to adapting, implementing and evaluating it in other contexts facing residual malaria in hard-to-reach and/or mobile populations. The process of transferring this intervention includes: diagnosis of the situation (malaria epidemiology, characteristics of the population affected) to define the relevance of the strategy; determination of the stakeholders and the framework of the intervention (research project or public health intervention); adaptation modalities (adaptation of the kit, training, distribution strategy); the role of community health workers and their need for training and supervision. Finally, evaluation needs are specified in relation to prospects for geographical or temporal extension. Malaria elimination is likely to increasingly involve marginalized people due to climate change and displacement of populations. Evaluation of the transferability and effectiveness of the Malakit strategy in new contexts will be essential to increase and refine the evidence of its value, and to decide whether it could be an additional tool in the arsenal recommended in future WHO guidelines.

Use of antimicrobials and other medical products in an ethnic minority context of South-Central Vietnam: A qualitative study of vulnerability

Despite the global threat of antimicrobial resistance (AMR), evidence on the use and quality of medicines at community level is limited, particularly in impoverished, rural areas where prevalence of (bacterial) infections is high. To better understand the processes that drive vulnerability to AMR' effects, this study aimed to assess social factors underpinning access to-and use of-medical products and healthcare, among people from the Raglai ethnic minority in Ninh Thuan Province, Vietnam. We conducted ethnographic research in eight villages in 2018-2019, using interviewing and participant observation methods for data collection. Different types of informants (including community members and healthcare providers) were selected using purposive sampling strategies and analysis was retroductive. Our findings show that, despite the existence of a government-funded health insurance scheme, Raglai people's flexible therapeutic itineraries did not systematically start with formal healthcare. Different types of care (private/informal, public, shamanic) were combined in parallel or in alternation, determined by distance to the provider, cost, workload, perceived diagnostic capacity, perceived severity and aetiology of the illness, and trust in the provider. Available medicines were often tablets dispensed in plastic bags containing labelled tablets, unlabelled tablets (in bulk) or tablets ground to powder. Treatment was often considered effective when it relieved symptoms, which led to abandonment of the treatment course. When symptoms did not speedily abate, the illness aetiology would be reinterpreted, and "stronger" medicines would be sought. The precarious socio-economic status of some Raglai drove them in cycles of severe poverty when additional unforeseen factors such as illness, animal disease or loss of crops arose, hampering access to (in)formal healthcare providers and/or appropriate diagnosis and treatment. We conclude that Raglai communities are structurally unable to buffer themselves against the threat and consequences of AMR. Despite this vulnerability, they are among the least targeted by efforts to optimize antibiotic use, which are concentrated in secondary and tertiary healthcare facilities targeted at urban populations.

Progress towards malaria elimination in the Greater Mekong Subregion: perspectives from the World Health Organization

Malaria remains a global health challenge, disproportionately affecting vulnerable communities. Despite substantial progress, the emergence of anti-malarial drug resistance poses a constant threat. The Greater Mekong Subregion (GMS), which includes Cambodia, China's Yunnan province, Lao People's Democratic Republic, Myanmar, Thailand, and Viet Nam has been the epicentre for the emergence of resistance to successive generations of anti-malarial therapies. From the perspective of the World Health Organization (WHO), this article considers the collaborative efforts in the GMS, to contain Plasmodium falciparum artemisinin partial resistance and multi-drug resistance and to advance malaria elimination. The emergence of artemisinin partial resistance in the GMS necessitated urgent action and regional collaboration resulting in the Strategy for Malaria Elimination in the Greater Mekong Subregion (2015-2030), advocating for accelerated malaria elimination interventions tailored to country needs, co-ordinated and supported by the WHO Mekong malaria elimination programme. The strategy has delivered substantial reductions in malaria across all GMS countries, with a 77% reduction in malaria cases and a 97% reduction in malaria deaths across the GMS between 2012 and 2022. Notably, China was certified malaria-free by WHO in 2021. Countries' ownership and accountability have been pivotal, with each GMS country outlining its priorities in strategic and annual work plans. The development of strong networks for anti-malarial drug resistance surveillance and epidemiological surveillance was essential. Harmonization of policies and guidelines enhanced collaboration, ensuring that activities were driven by evidence. Challenges persist, particularly in Myanmar, where security concerns have limited recent progress, though an intensification and acceleration plan aims to regain momentum. Barriers to implementation can slow progress and continuing innovation is needed. Accessing mobile and migrant populations is key to addressing remaining transmission foci, requiring effective cross-border collaboration. In conclusion, the GMS has made significant progress towards malaria elimination, particularly in the east where several countries are close to P. falciparum elimination. New and persisting challenges require sustained efforts and continued close collaboration. The GMS countries have repeatedly risen to every obstacle presented, and now is the time to re-double efforts and achieve the 2030 goal of malaria elimination for the region.