At both sites, staff had undertaken activities prior to the MDA: malaria prevalence surveys (which entailed blood draws) and, in Preah Vihear, nurses had been present in the villages for over a year (training, supervising treatment and RACD). At both sites, the previous activities were positively evaluated by villagers and village leaders.
Perceptions of the MDA and implementing organization
At both sites, villagers were familiar with the aim of the MDA “to eliminate” malaria. They were however often less aware of the intervention rationale—to treat asymptomatic infections. During the community engagement was the first time that most community members had heard messages about ‘drug resistant malaria’ and ‘asymptomatic carriers’. In Battambang, some members of the field team were confused about the science that underpinned the intervention. At both sites, previous treatment guidelines that emphasised diagnosis of malaria before giving anti-malarials prompted some confusion.
During the MDA, MORU became a well-known term. Community members also described generally positive opinions of staff’s efforts at eliminating malaria. Nonetheless, staff interpreted the drop in coverage during round 2 in 2015 as an indication that attitudes towards MORU had changed and that they had begun to see the team as outsiders. In response, representatives from the local health authorities took up more prominent roles in the third round of MDA.
In Preah Vihear, before the intervention, the initial description and notion of MDA was well-received by members of the target community, though it was viewed as a last-minute introduction. In addition to MDA prompting confusion regarding previous messages about overtreatment, MSF staff gained the impression that the non-governmental organization (NGO) was primarily associated with the treatment of symptomatic malaria. Few respondents made the link between MDA and the survey conducted the year before. Although the organization was well known, and their efforts to eliminate malaria positively received, it is possible that the change in approach and the new activities raised questions among villagers.
Incentives were provided in cash for participants in the Battambang MDA in all three rounds in 2015 and the first round in 2016. Intended to compensate participate for a day’s labour, the incentives were however not readily cited by villagers as a major reason for participation. The absence of financial incentives for two rounds of MDA in 2016 did not negatively impact coverage. No financial incentives were provided in Preah Vihear.
Written informed consent
Amongst villagers, the process of informed consent for MDA was sometimes viewed with suspicion and this raised concerns about the MDA. In Preah Vihear, a few villagers misunderstood the Khmer terms used for surveys and MDA, interpreting it as having connotations of experimentation and that participants would ‘discharge liability’. Learning from the experience of staff working in Preah Vihear, in the Battambang MDA, a more neutral term, “project” was used. Both MDAs required signed consent. In Preah Vihear, for a few villagers, this stoked fears that the signature could be used for political reasons or land grabbing. Such fears were not mentioned in Battambang.
The information sheet that accompanied the informed consent in Preah Vihear provided extensive details of the potential (albeit unlikely) adverse reactions of the anti-malarials. Staff suggested that this contributed to the range of health complaints that villagers reported after MDA (see below). Staff in Battambang were informed of this and adapted their information sheet accordingly to reflect the low likelihood of adverse reactions.
Perceived adverse reactions
In Battambang, MDA was conducted during the rainy season and coincided with seasonal bouts of mild cold and influenza-like illnesses. Some villagers attributed these illnesses to the anti-malarial and this had an impact on coverage in the second round, with an estimated 10% decrease in participation. Although study staff viewed the decline as a challenge, they were able to give an understandable explanation for the minor health complaints that villagers were experiencing at the time of MDA.
In Preah Vihear, MDA was conducted towards the end of the dry season and staff had no such easy explanation for the complaints that villagers experienced at the time of the MDA. In fact, staff, particularly the locally recruited village guides struggled to respond to villagers’ questions about perceived adverse reactions. News of adverse events spread through the villages and staff described them as a major reason why coverage declined in target villages. Based on history and physical examinations, MDA health staff confirmed that almost all of these complaints were unlikely to be related to the MDA.
At both sites, concerns about the adverse events that villagers attributed to the anti-malarial were compounded by several factors. First, many adverse events were seen as requiring medical attention—and in some cases in Battambang, because they did not seek help from the MDA health staff, this was viewed as an additional cost. Second, the adverse events were seen as potentially limiting one’s capability to work and to earn needed income.
In Preah Vihear, the adverse events prompted changes in attitudes towards the MDA. These were linked to rumours suggesting that the anti-malarial was different from that used by the VMWs. Linked to the misunderstanding about the nature of the MDA as experimentation, some villagers viewed it is a dangerous and potentially targeted at the Khmer people. Private practitioners were described as participating in spreading these stories.
The number of villagers who sought assistance at health facilities in Preah Vihear was so large that they were unable to deal with all requests for treatment. This may have been related to the presence of extra MDA nurses and an expatriate physician. Staff explained that participants could report and seek assistance for any health problem until 1 month after the last MDA dose and some villagers associated all symptoms/medical complaints during this period with the MDA. The availability of free healthcare and the presence of an ambulance and expatriate physician may have heightened concerns about the anti-malarial. There were also complaints about the treatment that was offered to palliate adverse events and about the costs of travelling to health facilities for this assistance, even those were reimbursed in both sites at a later stage.
In Battambang, people were concerned about having to purchase intravenous (IV) drug “kits” from private health providers to manage perceived adverse reactions to the study drugs. Although expensive, these kits were popular because of their perceived “powerful energising” effects and because they could be administered by a friend or neighbour (former soldiers who had received some medical training).
At both sites, villagers were also worried about the study because of the widely reported 2014 case of negligent needle practice by a health provider in Battambang Province, which led to multiple HIV infections . Staff in Battambang described this as a challenge during community engagement but it was not described as a reason for non-participation amongst villagers. In Preah Vihear, however, it was mentioned by villagers as a reason not to participate.
Local community engagement activities began around 6 weeks before the start of the MDA in Battambang and 3–4 weeks before in Preah Vihear. For the Battambang team, delays in the ethical approval procedure gave additional time for planning the community engagement (and the opportunity to incorporated lessons from the Preah Vihear). In Preah Vihear, staff—and villagers—were critical of the lack of time available during the community engagement prior to the MDA to provide adequate information. Field staff in Battambang also described being rushed to provide adequate community engagement.
Differences in the number of personnel who were responsible for community engagement explain part of this: in Battambang a team of five (later six) field staff were engaged specifically in the community engagement, and senior members of the study staff also took active roles in community engagement activities in the four villages; in Preah Vihear, two health promotion officers (daily workers, not fixed MSF staff, but trained for this specific task) were charged with delivering community engagement across eight villages (nurses were present in villages only during 3 days). The number of intervention villages also played a role.
Staff involved in the Battambang MDA adapted the community engagement to the local context, according to formative research prior to and during the MDA. This include initial interviews with local community leaders and semi-structured interviews with villagers 1 week after each round of MDA. The semi-independent staff who conducted interviews were able to feedback information to the team who implemented MDA. The presence of the study team in the villagers during 7 days after each round of MDA meant that they were able to respond to complaints and concerns in small gatherings or house-to-house visits.
This capacity to adapt community engagement in Battambang led staff to alter their approach after the decline in participation in round 2 during the 2015 MDA. Prior to round 3, MORU staff took less prominent roles in meetings and rather local health staff from the government-run facilities led the events. Coverage subsequently increased in round 3 and this model based on local health staff was used in the 2016 MDA, during which coverage remained high (despite the removal of incentives in rounds 2 and 3).
In Preah Vihear social science research was conducted retrospectively to understand the reasons for the rapid decrease in participation in the MDA. MDA health staff were present in local facilities during and after the first round of MDA who were able to listen and respond to villagers’ concerns. Because the MDA was halted, community engagement was not adapted. The MSF team had initially assumed that gaining the approval of the village leaders, would be sufficient to ensure that all villagers would agree to participate. The leadership dynamics in each village were however more complex. Other formal and informal leaders (such as teachers, policemen, monks, and representatives of political parties) also influenced other people’s decisions about whether to participate in MDA.
Malaria as a health concern
In Battambang, in spite of the recent declines in clinical cases, and a limited understanding of the disease, malaria was a concern to villagers. This concern was often based on past experiences, for example, malaria was a major cause of ill health when some of the study villages were settled over 20 years ago. People also recognized that a bout of malaria has financial implications, particularly in terms of opportunity costs when a sick person is unable to work. Villagers were therefore generally receptive to malaria prevention interventions and appreciated the effort to ease the burden of disease in their communities.
In Preah Vihear, some villagers also described how they wished to avoid illness because of its financial implications. However, accustomed to the “test and treat” approach to malaria control, most people were more comfortable treating themselves when they were sick than taking an anti-malarial when feeling healthy.