Community perceptions of targeted anti-malarial mass drug administrations in two provinces in Vietnam: a quantitative survey
© The Author(s) 2017
Received: 7 September 2016
Accepted: 20 December 2016
Published: 6 January 2017
As part of a targeted malaria elimination project, mass drug administrations (MDAs) were conducted in Vietnam. The impact of MDAs on malaria transmission depends largely on the efficacy of the anti-malarial drug regimen, the malaria epidemiology in the site and the population coverage. To explore why some people participate in MDAs and others do not, a quantitative survey of the villagers’ perceptions was undertaken in Vietnam.
In 2013/2014 MDAs were conducted in a village in Binh Phuoc province and a village in Ninh Thuan province. Within three months of the drug administration, 59 respondents in a village in Binh Phuoc and 79 respondents in a village in Ninh Thuan were randomly selected and interviewed.
Comprehension of the purpose of the intervention was of paramount importance for participation in the intervention. Respondents aware that the intervention aims to protect against malaria were significantly more likely to participate than respondents who were unaware of the MDA’s purpose. Secondly, how and by whom villagers were informed was critical for participation. There was a strong association between sensitization by an informant such as a member of the local health team with participation in the intervention.
The study suggests several approaches to increase participation in mass drug administration campaigns. Training trustworthy informants to sensitize the study population is critical to maximize village participation in this setting. To achieve high coverage the entire community must understand and agree with the intervention.
With the growing threat of multidrug resistance in the Greater Mekong subregion, the international malaria community is recognizing the need for additional measures, including mass drug administrations (MDAs) as a component of rapid malaria elimination efforts . Although their popularity has gone through cycles, MDAs have been used for malaria control and elimination for more than a century . The impact of MDAs on malaria transmission is variable . Effectiveness depends on the efficacy of the anti-malarial drug regimen and the proportion of the population participating . The duration of the impact depends to a large part on local malaria epidemiology. While there is an extensive literature on the efficacy of anti-malarial drugs, information on how to achieve maximum coverage is limited.
A recent literature review found 28 detailed descriptions of community engagement in anti-malarial mass administrations over the last 100 years . Despite the heterogeneity in populations, community engagement and study methods, the authors identified several commonalities. The top-down approach based on hierarchical structures such as government, village leaders and village elders was traditionally relied-on to mobilize the populations. The use of authority which for example could be relied on during smallpox eradication campaigns  has become less popular and less successful. Instead investigators depend more on a bottom-up approach based on the targeted community itself . The authors of the review concluded that both approaches top-down and bottom-up are essential for success . The most successful campaigns invested in a two-pronged approach by engaging the leaders of the targeted communities as well as the community members themselves. A better understanding what makes a successful campaign would be helpful for the design of future campaigns.
As part of a targeted malaria elimination (TME) project, MDAs were conducted in two villages in Vietnam. The aim of the present study was to identify factors associated with MDA participation among a random sample of community members in two villages.
The mass drug administration
A questionnaire used in a survey following a MDA in West Africa was adapted to the local context and translated into Vietnamese . The interview guide and questionnaire are included in the Additional file 2. The instrument included a set of questions that explored opinions and knowledge related to malaria and its control. Interviewers were trained to administer the instrument in a neutral fashion to minimise bias towards preferred responses. At both villages, the interviews were completed within three months of the completion of the MDAs. A sample of participants and non-participants were randomly selected from the database collected during the MDA. Due to an expected correlation in the answers from multiple members of a household only one person was interviewed per household. To be eligible, he or she had to be over 18 years of age, residing in the village at the time of the MDA and consent to be interviewed. A study physician who had neither participated in the engagement campaign nor the drug administration conducted the interviews.
Data management and analysis
The questionnaires were single-entered into a database and checked for consistency. Inconsistent data were verified and corrected. The data were merged with a dataset recording the participation in the MDA. Residents who took zero MDA doses are defined for the purposes of the analysis as “non-participants”, residents who took at least one but less than nine doses are defined as “partial-participants”, and residents who took all nine doses are defined as “full-participants”. Interviewees are referred to as respondents. The administration of a single low dose primaquine with the third dose DHA/piperaquine during each round was not included in this analysis. In the initial analysis, socio-economic and demographic characteristics were explored to explain differences in degrees of participation. Comparisons of categorical data were made using Fisher’s exact or Pearson Chi squared test as appropriate. Continuous data were compared using Student’s t test or in the case of more than two categories, with Kruskal–Wallis equality-of-populations rank test. Considering the large number of variables and hypotheses tested only a conservative p-value <0.01 was considered significant. A logistic regression model was used to test the association between predisposing variables and the outcome (non-participant vs. participant i.e. ≥1 dose anti-malarials). Terms that appeared thematically relevant and/or were significant in the univariate analysis were explored in the model. In the final model, only variables significant below p < 0.01 were retained, namely literacy, knowledge of the causes of malaria, recall of being informed about the MDA, who explained the MDA, comprehension of the rationale and finally the purpose for the MDA. Statistical analyses were performed using Stata 14.1 (StataCorp LP, College Station, TX, USA).
Characteristics of the 138 respondents
Number (%) by participation
VN10 Binh Phuoc
VN 30 Ninh Thuan
Always lived in study village
Relocated into study village
Can read and write?
Do you have children?
Adjusted odds ratios of 138 respondents for variables associated with participation in the MDA
Partial and full participants
Median age in years (IQR)
Believes that malaria is the village’s main health problem
Believes fever is a symptom of malaria
Doesn’t know causes of malaria
Doesn’t recall being told about the MDA
Who explained MDA (DHT)
Believes everybody should participate in the MDA
Believes the medicine protects against malaria
The study found that the pivotal difference between participation and non-participation in the MDA was the recollection of being adequately informed about the campaign. Villagers who recalled being informed about the campaign were much more likely to participate than those who did not. Specifically, residents who had been explained about the MDA by the local health team were significantly more likely to complete the entire course of the drug administration. More qualitative interviews would be needed to explore whether trust or multiple factors beyond trust influenced these decisions. A detailed and locally-appropriate explanation of anti-malarial drug administration campaigns is needed for an understanding of the complex concepts of malaria transmission, the role of subclinical infections in malaria transmission and ultimately the acceptance of interventions to interrupt transmission. Demographics also played a role in participation; village residency, older age, ethnicity, religion and literacy were associated with participation. In contrast, the occupation of the respondents (most of whom were farmers) and whether they had children did not make a significant difference in participation.
This study relied on recollection and opinions which may be biased and inaccurate. This is illustrated by the stated reason for non-participation. Nearly 45% of the non-participants said that they were travelling at the time of the MDA. When untrue, this response may have allowed the respondent and the interviewers to “save face”; to spare the interviewer, as well as the respondent, the embarrassment of stating the real reason for non-participation. Although none of the respondents suggested absence of trust in the researchers or a dislike for the drugs as reasons for non-participation, this does not necessarily exclude such perceptions. To get a more detailed understanding of the true reasons for incomplete or non-participation including deeper motivations, fears and apprehension, in-depth interviews and focus group discussions will be needed [18, 19]. A second limitation of this study is that the interviews were conducted only in two villages after MDA and with a limited number of respondents. A larger number of respondents would potentially increase the generalizability of the findings. Nevertheless, the study had sufficient statistical power to detect differences between full, partial, and non-participation.
The findings underscore the importance of community mobilization prior to drug administration campaigns and could inform how campaigns can be implemented in an effective way to maximize participation. The study provides evidence about the importance not only of what information is disseminated but where the information comes from. Messages, which made an impact, came from a trusted familiar source of heath information. It may be necessary to invest time and money to establish such core information providers to sensitize the entire community appropriately long before an anti-malarial drug administration campaign is undertaken. Research is under way to better understand which means of communication to explain the underlying concepts and purpose of MDA. It is also important to identify demographic strata that are less likely to participate and special efforts should be undertaken to engage this subgroup of the community. In the study villages, it would have been worthwhile to specifically visit and engage members of two ethnic groups, Raglai and Kinh. The demographic data also suggest that it may be worthwhile to take extra efforts to include younger, less educated and more recently arrived members of the community to treat all members of the community.
The findings from this study are consistent with recently published findings from a quantitative study following four mass administrations of anti-malarial drugs along Thai-Myanmar border areas . While the findings in two of the four villages were comparable to the findings reported here the other two villages had issues which resulted in fragmented communities suggesting that a cohesive community is a helpful if not essential predisposition for successful mass drug administrations. Several qualitative and quantitative studies following anti-malarial mass administrations were conducted in The Gambia, West Africa. There the researchers found travel, perceived adverse drug reactions and rumours, inconveniences related to the logistics of MDA (e.g. waiting times) and the perceived lack of information about MDA were critical reasons for non-participation [17, 21, 22]. While the research into factors related to the participation in mass administrations of anti-malarial drugs is somewhat limited there is a broad experience how to engage communities in other biomedical interventions including interventions against the transmission of HIV, tuberculosis, and vector-borne disease . This body of work has resulted in a framework for community engagement in global health research which has applicability for MDAs. Lavery and co-workers suggest twelve points to consider for effective community engagement. The provision of information and the building of trust feature prominently in the framework suggesting some universal principals which have to be respected for successful community engagement .
The elimination of malaria poses large challenges as all community members, not only high risk groups have to participate in interventions. The findings from this study suggest several approaches to maximize participation in mass drug administration campaigns and thereby contribute to a broader understanding what makes community engagement successful. The concepts underlying anti-malarial mass administration are complex and need time to be explained especially if the target population has only a primary education or less. In the absence of a detailed understanding of the rationale the residents in the target villages must be able to trust the people providing information about the campaign. Training and investing into the establishment of a trustworthy team to sensitize the study population may be critical to maximize village participation in this setting. To achieve high coverage the purpose of the intervention must be understood by the entire community.
T-NN, PNHT, NTH, NTT, DHS, NVD, HHQ and TTH: data collection and study implementation; T-NN, TTH, LvS, PYC, AMD, NJW, NPJD: study design; LvS: first draft; LvS, T-NN, TTH revised the manuscript. All authors read and approved the final manuscript.
We thank the respondents for taking the time to participate in the study. We thank Jacqueline L. Deen for editing the text and the anonymous reviewers for their suggestions.
The authors declare that they have no competing interests.
Ethical approval for the study was received from the Institute of Malariology, Parasitology and Entomology in Ho Chi Minh City (185/HDDD dated 15 May 2013), the Institute of Malariology, Parasitology and Entomology in Qui Nhon (dated 14 Oct 2013) and the Oxford Tropical Research Ethics Committee (1015-13, dated 29 Apr 2013). Individual informed consent was obtained from each participant.
This work was supported by the Welcome Trust (Reference 101148/Z/13/Z) and the Bill & Melinda Gates Foundation (BMGF OPP1081420).
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