“We were afraid of the lion that has roared next to us”; community response to reactive focal mass drug administration for malaria in Eswatini (formerly Swaziland)

Abstract

Background Reactive focal mass drug administration (rfMDA), or presumptive treatment without malaria testing of household members and neighbours of a passively identified malaria case, is currently being explored as a possible malaria elimination strategy in low transmission settings. One of the primary factors determining the effectiveness of rfMDA on reducing or interrupting transmission is achieving high coverage of the target population with drug administration. This study aims to explore the acceptability of rfMDA and identify facilitators and barriers to its potential implementation, as well as the community’s general knowledge, attitudes and beliefs with regard to malaria elimination. Methods A qualitative study was performed using focus group discussions (FGDs) among villagers that received rfMDA through the National Malaria Control Programme in the low transmission setting of Eswatini as part of a 2-year clinical trial. FGDs were audio-recorded, transcribed and translated into English. All transcripts were managed in Dedoose and underwent qualitative content analysis. Results The majority of participants perceived their community to be at high risk of malaria. Witnessing others in their community suffer from malaria, proximity to Mozambique, various ecological factors, and the presence of mosquitoes contributed to this perception. The greatest motivator of participation in rfMDA was witnessing someone else suffer from malaria, since most participants had not personally experienced malaria themselves. Participants valued the education on rfMDA and on malaria in general, particularly when communicated by nurses and other health workers from the Ministry of Health. Participants were overwhelmingly motivated to participate in rfMDA in order to obtain protection from malaria. Most participants did not understand the concept of sub-clinical infection and, therefore, did not perceive the anti-malarial medication given in rfMDA to be a treatment medication. Conclusions Perceived risk for malaria was a major driver of acceptability; therefore, future intervention campaigns could aim to better quantify risk to inform interventions and encourage uptake. There were misunderstandings about the asymptomatic reservoir of parasites in humans. Given that this phenomenon is the rationale for rfMDA, this misunderstanding could threaten the uptake of the intervention if it persists in the community. Using local authorities to deliver messaging, additional education on this concept with re-inforcement that risk of malaria is ongoing, even in the absence of frequent cases, may help to maximize and maintain acceptability.

Effectiveness of reactive focal mass drug administration and reactive focal vector control to reduce malaria transmission in the low malaria-endemic setting of Namibia: a cluster-randomised controlled, open-label, two-by-two factorial design trial

“…High coverage and acceptability could have been due to effective community sensitisation activities before the study, 10 ongoing engagement by staff during pharmacovigilance and follow-up visits, and high motivation for individuals to participate because of the perceived threat of malaria when there was a recent case in their neighbourhood. 34 Our study has some limitations. First, the large differences in crude and adjusted incidence and prevalence estimates were due to an imbalance of factors in the study arms that were associated with the trial outcomes.…”

Effectiveness and safety of reactive focal mass drug administration (rfMDA) using dihydroartemisinin-piperaquine to reduce malaria transmission in very low-endemic setting of Eswatini: a pragmatic cluster randomised controlled trial

“…Adherence to presumptive treatment with DP was high, and as reported elsewhere, acceptability was high. (18) Importantly, there were no serious adverse events (SAEs).…”

“…The primary outcome of the trial was the cumulative incidence of malaria cases by study cluster over two-years of follow-up. Secondary outcomes reported here include safety and adherence (acceptability has been reported elsewhere(18)). Infection prevalence and seroprevalence at two-year follow-up were originally also secondary outcomes but the endline cross-sectional survey was not conducted due to a shift in priorities within the Ministry of Health.…”

“…To elicit ongoing feedback regarding the conduct and burden of the study intervention, patients and the public were engaged in an ongoing basis through focus group discussions, the results of which are published elsewhere. (18)…”

Effectiveness and cost-effectiveness of reactive, targeted indoor residual spraying for malaria control in low-transmission settings: a cluster-randomised, non-inferiority trial in South Africa

“…Previous studies have evaluated the effect of adding reactive targeted interventions, including IRS and drug administration, to routine population-wide measures, to further reduce or eliminate malaria. 13 , 14 , 45 , 46 , 47 A trial in Namibia showed effective reduction of malaria incidence through reactive focal mass drug administration and reactive focal IRS, alone and in combination, when added to standard IRS. 14 Our trial is unique in using a non-inferiority design to assess whether replacing annual IRS campaigns with reactive IRS targeting at-risk neighbourhoods would be safe and prevent malaria from surging out of control.…”