Table 2 Main themes of actual and predicted challenges listed in monthly/quarterly reporting

Recruitment and retention issues

Patients not from town so anticipated to be difficult to follow up

People go back home for holidays and therefore difficult to recruit and follow up

Low load of cases due to end of malaria season

Private sector: patient treated in private sector before referral to study, lack of incentives for private providers to

Many patients screened are migrants and cannot be included in studies

Low numbers of border crossings

High number of refusals

Weekly target set to mitigate inability to reach sample size

Gather more information on those who refuse to mitigate sampling bias due to refusals

Lack of support from local authorities. Local authorities do not see malaria as a health problem anymore. There are other more pressing diseases

Lack of cooperation from village chiefs

Environmental/external

Flooding

National election campaign

Unpredictability of border activities makes sampling difficult

Limited resources

Not enough staff to cover provincial level study

Transport issues

Expensive repair fees for hospital equipment compounds challenges created by power transformer explosion

(Lab loses electricity)

Sysmex machine out of service and needing engineer attention

Unable to find reagents and samples not processed in time

Data quality issues

Difficulties in communicating with participants

Delays in obtaining laboratory results

Poor quality samples due to transportation issues e.g. freezing of samples, sample storage and analysis delayed due to blackouts in remote and rural areas, samples coagulated due to long travel distances and flooding during the rainy season

Staff/training

Delayed recruitment of assistance

Training slow due to lack of staff

Staff start losing their malaria diagnosis and treatment skills due to low malaria burden