Study site
Banmauk Township is located in the Sagaing Region of northern Myanmar and was selected as a study area because of its persistently high malaria burden. In Banmauk, the malaria burden has been declining, with an annual parasite incidence (API per 1000 population) of 11.0, 6.5, and 3.8 in 2016, 2017, and 2018, respectively. Plasmodium falciparum accounted for > 80.0% of total infections, but P. vivax has become the dominant parasite in some villages. As of 2019, four major organizations (National Malaria Control Program, University Research Co., Population Services International, International Organization for Migration) were intensively implementing malaria control activities in the township, including but not limited to malaria surveillance activities through trained village health volunteers, regular active case detection, awareness-raising campaigns, and distribution of bed nets. The township is gradually moving toward the pre-elimination phase, currently focusing on residual malaria cases and potential transmission foci.
The top five P. vivax prevalent villages were selected for this study, with a total population of approximately 3000 people living in 609 households. In each village, at least a government health center or a village health volunteer oversees the village's health aspects. Within a 10-km range, there are no gold mines or other large-income opportunities that might attract migrants or mobile populations to stay at the selected villages. Conversely, this lack of occupational opportunity may lead to the relocation of some villagers away from the study villages. Mass distribution of long-lasting insecticide-treated nets (LLINs) occurred every 3 years, followed by yearly topping-up for high-risk individuals such as pregnant women, small children, and forest-goers. A mixed-methods study was conducted in these five villages where the TPT activity was proposed.
Study samples
A mixed-methods study design was chosen to combine quantitative approaches, which would represent the five study villages, with a qualitative component, which was meant to provide a more in-depth understanding of the same study villages. For the quantitative study, household leaders or their representative from the five villages were targeted for inclusion. If the household leader could not participate, the next in line from the same household was asked to participate. One person from each of the 609 households was recruited. The quantitative study inclusion criteria included being at least 18 years of age, living in the respective village for at least a year, and being sufficiently healthy to answer questions during an interview.
The qualitative component of this study targeted two groups who would play important roles in the planned TPT campaign: community members living in the selected villages and government healthcare officials working in the selected villages. Ten community members from each village, 50 respondents in total, were recruited for this study using purposive sampling. This sample size was chosen as a balance between a representative sample from the villages and labor and time constraints inherent to qualitative data collection [20]. Inclusion criteria among community members included being > 18 years old, living in the respective village for at least 5 years, and having sufficient knowledge of the overall situation of the villages. Recommendations from village administrators were also considered for participant selection. Furthermore, the sex ratio of participants (aiming for balance), age distribution, and a mixture of different occupations and education groups were also considered. All government healthcare officers assigned to the five selected villages were invited to participate in the qualitative study. Inclusion criteria included having at least 2 years of service. Six midwives and four public health staff (grade II) participated in the study.
Study tools
A cross-sectional mixed-methods study was deployed in July 2019, which was coincident with the rainy season. For the quantitative part, the face-to-face interviews using structured questionnaires were given to 609 household leaders or their representatives. The questionnaire was first developed in English, based on qualitative data gathered in Thailand and Myanmar. It was then translated into the Myanmar language by the research team. The questionnaire included four main themes addressing: (i) general characteristics of the respondents, (ii) malaria knowledge regarding transmission, diagnosis, symptoms, treatment, and prevention of malaria, (iii) attitudes towards severity, beliefs, and misconceptions, and (iv) practices, including potential agreement to participate in a TPT campaign (Additional file 1).
A standardized qualitative guideline in the Myanmar language was used to collect qualitative data through in-depth interviews (Additional file 1). The first part of the guideline was for reporting general characteristics of the respondents, including age, gender, occupation, and education for community members. In addition, it included the position and experience of healthcare providers. The second part of the guideline was intended for qualitative data collection. The contents for the community addressed previous experiences with malaria and their potential agreement to participate in upcoming TPT exercises. In the guidelines for healthcare provider respondents, there were open questions regarding current malaria trends, practices in prescribing PQ, and possible challenges to implementing TPT.
Data collection
Four data collection assistants with university degrees were trained for 2 days. The training modules included sessions on orientation to both components (quantitative and qualitative) of the study, objectives, interview procedures, and ethical precautions. Practical sessions were also organized and supervised by PLA, MTS, and MPK. For the quantitative study, the assistants went to the selected villages and contacted respective village leaders to ask for the household listing, including the names of household leaders. Individual households were visited, and face-to-face interviews were conducted. A standardized information sheet was used to explain the nature of the study, flow of the interview, and right to withdrawal from the interview at any time for all potential respondents. An interview took no more than 15 min. Similarly, the face-to-face in-depth interviews for the qualitative component of this study were conducted at each household of respondents. While one data assistant asked the respondent questions, another assistant wrote down the verbatim report. The answers were also recorded. Each in-depth interview took approximately 30 min. The consent forms were signed by the respondents before commencing the interviews. Respondents who were illiterate were asked to provide consent by providing a right thumb print (illustrated on the consent forms). The study team also prevented other persons who could influence the participants' answers from entering the interviewing environment.
Data entry and analysis
The quantitative data were entered into Microsoft Excel 2018 (Excel for Mac, version 16.16.27, Seattle, WA, USA) spreadsheets and analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Macintosh, version 23, IBM Corp., Armonk, NY, USA). The data were entered and cross-checked daily to eliminate data entry errors. Descriptive statistics including percentage, mean, median, standard deviation, and minimum and maximum values were presented. In addition, simple logistic and multivariable logistic regression models were used to investigate possible associations between variables and the reported agreement to participate in TPT ("1" if agreed to participate and "0" if not). Crude odds ratios (cORs) and model-adjusted odds ratios (aORs) were calculated together with 95% confidence intervals (CIs).
Sixty in-depth interviews, including the answer sheets from 50 community respondents and 10 healthcare professionals, were also systematically analyzed. All the interview notes were first checked by the lead authors for typos, textual errors, and repetitions. The general characteristics of the respondents were entered into Microsoft Excel 2018 spreadsheets, and cumulated numbers along with the proportions were calculated. Second, the qualitative answers in the Myanmar language were translated into English independently by PLA and MTS. The correctness and completeness of transcripts were thoroughly checked by MPK, LC, and DMP. The intended meanings of the original texts were also ensured by comparing them with English translations. Then, each transcript was coded line by line and roughly grouped under similar topics. The mindJet MindManager software system (version 12) [21] was employed to analyze the textual data and intensively visualize all of the contents for community respondents and healthcare providers. The constructed sentences were finalized and confirmed among all authors until all the conclusions were mutually agreed upon.