The majority of respondents participated in all three rounds of MDA, which is necessary to clear parasitaemia completely [6, 9]. This study demonstrates that contact with TME staff, particularly during the community engagement meetings, was key to participating in the MDA. Villagers were also likely to be complete participants if all other household members participated. Among the community engagement activities that accompanied the MDA, village meetings were one of the most frequent means of delivering health education to the villagers.
A minority of participants never took part in MDA (n = 8) because of fears about the blood testing. Others who could not complete the participation (n = 9), gave reasons such as travelling, busy due to work and adverse events due to the medicine. Such explanations are consistent with those offered for partial or non-participation in past MDAs in the Gambia [19,20,21], Vietnam [14] and the Thai–Myanmar border regions [9]. The villagers’ reasons for partial or non-participation were discussed in meetings, and those who voiced concerns about MDA were sought out and provided with additional health education during house-to-house visits [16].
As has been highlighted elsewhere, the community engagement strategy played an important role in promoting MDA coverage. For example, in Vietnam, participation in TME was also more likely among villagers who could recall that someone had explained to them “what MDA is” [14]. In Vanuatu, community engagement activities provided a forum for sharing information about the study and resolving concerns raised. This ultimately contributed to the elimination of malaria [22].
Community meetings have been an integral part of MDAs in past [7]. In The Gambia, district level government officials led village meetings in which study objectives and methods were discussed and concerns and issues raised by villagers were addressed [23]. In Indonesia, villagers chose volunteers who held monthly meetings and conducted house-to-house health education [24]. In Kenya, meetings with authorities and trained volunteers were held at different community locations, such as schools and trading centres [25]. In Nicaragua [26], Liberia [27], Cambodia [28] and Sierra Leone [29] meetings were held as part of a stepwise process of community engagement for MDA.
The community engagement and other TME activities were coordinated with volunteers from each village. Through the volunteers, the villagers were able to take an active role in deciding on and executing TME activities. Such an approach has been recognized as a major element of effective community engagement [7, 17, 18, 22] and community members taking more prominent roles in the design of community engagement had a positive impact in population coverage in a recent MDA in Cambodia [10].
In addition to the community engagement, villagers’ experience of the TME study as a whole influenced their participation. Respondents who liked all the components of TME and thought that TME was a worthwhile activity participated in the MDA. Even though study staff made the distinction between community engagement and the clinical study, villagers tended to view the range of activities as part of one “project”, which is understandable given the integrated nature of community engagement within TME. Similar findings were reported from a TME study in Myanmar where villagers and staff considered community engagement an integral part of TME [30]. Consistent with the findings from Laos, perceptions such as “MDA was important” that referred to the whole study was found to be associated with participation in The Gambia [20].
The results also indicate a role for social relationships in uptake of MDA. Villagers were more likely to be complete participants if all household members participated in the study. In Laos, a high value is placed on familial cohesion and integrity [31], and in the study villages, household hierarchies, usually led by a male household head, are important [32, 33]. There was also a tendency for conformism across households in TME villages, likely to be rooted in villagers’ Lao Theung identity and the traditional system of mutual help between the households [32]. As previous ethnographic research has described, Lao Theung communities demonstrate a system of mutual support and labour exchange between households, for example work in the field, housing construction and other daily tasks. This is often termed “aw wan sai wan” (to take a day and to give a day) [34]. This interdependence was reflected in the communal community decision, which villagers often expressed as “If all participate, I will participate”.
As well as raising awareness of the study, increasing villagers’ familiarity with malaria, and addressing misconceptions, participation in village-wide meetings also generated pressure to conform and participate. Repeated home visits and interactions with TME staff and volunteers, gestures of commensality—sharing and eating food together—and participating in their rituals also strengthened social relationships. Developing ties of this kind, which went beyond the formal researcher-respondent relationship, prompted reciprocity and encouraged participation. In Myanmar, by following the social conventions (sharing traditional foods with the villagers, participating in social activities, such as funerals and festivals), study staff were able to build social relationships and garner trust. Sometimes this meant that villagers participated in MDA in spite of lack of a clear understanding of the intervention [30]. In The Gambia, developing social relationships between researchers and participants, which were akin to familial bonds, has been recognized as key to building trust and for participation in clinical trials [35].
Strengths and limitations
This study took place alongside a clinical trial of TME, which entailed a carefully planned programme of community engagement that began 6 months before the MDA. Such intensive community engagement may not be possible for MDAs that are part of large-scale malaria control programmes. As part of large-scale implementation, it is also unlikely that blood surveys would accompany the MDA. Further research is needed to assess the factors that influence participation in large-scale mass anti-malarial administrations.
The questionnaire used for this study, has been employed in locally adapted versions from several previous surveys of factors influencing participation in MDA. The questionnaire also underwent extensive pretesting. However, using a questionnaire alone limits the depth of information on villagers’ reactions to TME, community engagement and nature of social relationships. Additional qualitative data collection will provide a more nuanced understanding of attitudes and behaviors when offered MDA in this context. Additional qualitative data collection, particularly using observations will provide insight into whether villagers’ responses were influenced by desirability bias.
In this study, the low number of partial or non-participants limits statistical comparison and increases the likelihood of type 1 error. In addition, this low sample in one of the arms within outcome variable also affects the sensitivity and specificity of the model. Future studies with large sample size with comparable arms are required for robust statistical assessment.